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THOMAS    MORGAN    ROTCH,    M.  D. 


PEDIATRICS 


The  Hygienic  and  Medical  Treatment 


OF 


CHILDREN 


BY 

CHARLES  HUNTER  DUNN,  M.  D. 

INSTRUCTOR  IN  PEDIATRICS,  HARVARD  UNIVERSITY 
PHYSICIAN  IN  CHIEF  AT  THE  INFANTS'  HOSPITAL 


FOUNDED  UPON  THE  TEACHINGS  OF  THOMAS  MORGAN  ROTCH,    M.  D. 


VOLUME   I 

Second  Edition 


THE  SOUTHWORTH  COMPANY,  PUBLISHERS 
TROY,  NEW  YORK 
1917 


Copyright   19 17 
By  The  Southworth  Company 


To 

Clarence  John  Blake,  M.D.,  O.M.  (Vienna),  F.A.C.S. 

Professor  of  Otology  (Emeritus),  Harvard  University 

This  Volume  is  Inscribed 

As  a  tribute  to  his  high  professional  attainments  and  to  his  unfailing 

interest  in  the  welfare  of  children,  and  in  grateful 

remembrance  of  many  acts  of  kindness 

By  the  Author 


PREFACE 

The  "Pediatrics"  of  Dr.  Thomas  Morgan  Rotch  was  for  many 
years  the  official  text-book  used  in  the  Harvard  Medical  School. 
Professor  Rotch  originated  many  new  ideas,  and  his  book  contained 
many  contributions  of  permanent  value  in  the  teaching  of  pediatrics. 
The  last  edition  was  published  in  1906,  and  is  now  entirely  out  of 
date.  At  the  time  of  Dr.  Rotch's  death,  he  was  contemplating  the 
bringing  out  of  a  new  edition. 

It  seemed  a  pity  that  the  permanent  and  distinctive  features 
of  Dr.  Rotch's  teaching,  which  constitute  the  foundation  of  the 
teaching  of  pediatrics  at  Harvard,  should  not  be  preserved  in  written 
form.  As  much  therefore  of  this  teaching  as  has  seemed  to  the 
author  of  permanent  value,  has  been  incorporated  in  the  present 
work,  with  such  revision  as  modern  progress  demands. 

The  work  is  not,  however,  designed  to  be  merely  a  revision  of 
Dr.  Rotch's  book.  It  is  designed  to  be  an  entirely  new  modern 
text-book  of  the  diseases  of  infancy  and  childhood. 

Recent  progress  in  the  diagnosis  and  treatment  of  disease  is  be- 
coming more  and  more  centered  upon  the  problems  of  etiology.  For 
this  reason,  especial  attention  has  been  devoted  to  the  discussion. of 
the  causes  of  the  various  diseased  conditions  of  early  life.  Modern 
diagnosis  concerns  itself  less  with  names  than  in  former  times,  and 
consists  in  a  recognition  of  the  nature  of  the  lesions  and  functional 
disturbances  which  constitute  disease,  and  of  their  causes.  Modern 
treatment  concerns  itself  mainly  with  the  prevention  or  removal  of 
etiological  factors. 

Progress  in  knowledge  is  so  rapid,  that  before  a  book  on  any  sub- 
ject in  medicine  is  published,  it  is  likely  to  be  already  out  of  date. 
One  reason  for  this  is  that  the  writers  of  text-books  hesitate  to  in- 
corporate many  new  advances  in  research  for  fear  that  they  will  not 
stand  the  test  of  final  proof.  This  leads  to  the  exclusion  of  much 
material  which  does  prove  of  final  value,  and  justifies  the  criticism 
that  the  latest  advances,  the  things  which  are  being  most  widely 
discussed,  are  not  to  be  found  in  the  most  recent  text-books.  The 
author  has  in  this  book  attempted  to  obviate  this  difficulty,  by  means 
of  a  special  subdivision  under  each  disease,  which,  under  the  heading 
of  Problems  and  Research,  deals  with  the  most  recent  advances  in 
scientific  medicine,  and  summarizes  the  problems  awaiting  future 
solution.  The  reader  can  thus  easily  distinguish  the  proven  facts 
from  the  interesting  and  suggestive  theories. 


VI 


Preface 


The  author  acknowledges  his  indebtedness  to  Dr.  WilHam  W. 
Howell,  and  Miss  Margaret  Farquhar,  Head  Social  Worker  at  the 
Infants'  Hospital,  for  many  valuable  suggestions,  to  Dr.  Joseph  I. 
Grover  for  revision  of  manuscript,  to  Dr.  John  W.  Hammond  for 
assistance  in  collecting  material  for  the  division  on  gastro-intestinal 
diseases,  to  Dr.  William  Weston  for  supplying  material  for  the  article 
on  pellagra,  and  to  Dr.  Percy  Brown  for  selecting  and  collecting 
the  roentgenograms. 


CONTENTS 

DIVISION  I 

THE  NORMAL  CHILD  PAGE 

I. — Introduction i 

II. — ^The  Infant  at  Term 3 

Physical  Examination 3 

Internal  Structure 5 

III. — Normal  Development 8 

Physical  Examination 8 

Internal  Structure 27 

IV. — Hygiene  and  Care  of  Normal  Infants 34 

Care  of  the  Newborn 34 

Weighing '. 35 

Bathing 35 

Care  of  the  Mouth  and  Teeth 36 

Care  of  the  Skin 37 

Care  of  the  Genitals 37 

Care  of  the  Hair 37 

Clothing 37 

Sleep 42 

F  esh  Air  and  Going  Outdoors 42 

Exercise 45 

Hygiene  of  the  Nervous  System 46 

Training  and  Discipline — Habits 48 

The  Nursery 51 

Nursery  Maids 52 

Prevention  of  Exposure  to  Contagion 53 

Summer  Resorts 53 

The  Daily  Routine  of  the  Normal  Child 53 

DIVISION  II 

disease  in  early  life 

I. — Etiology  and  Classification 55 

The  Causes  of  Disease 56 

How  the  Various  Causes  Act  in  Producing  Disease 57 

The  Classification  of  Disease 59 

II. — Pathological  Anatomy 60 

III. — Symptomatology  and  Diagnosis 63 

The  History 63 

a.  Significance  of  Symptoms  in  Early  Life 64 

b.  The  Family  History 64 

c.  The  Previous  History 65 

d.  The  Present  Illness 66 

e.  General  Questions  as  to  Symptoms 67 

The  Physical  Examination 67 

a.     Method  of  Examining  a  Sick  Child 67 


viii  Contents 

III. — Symptomatology  and  Diagnosis — Continued. 

The  Physical  Examination — Continued.  page 

b.  General  Examination  of  the  Body 72 

(i)     Nutrition,  size,  weight 73 

(2)  Skin 73 

(3)  Position  of  the  body 73 

(4)  Mental  condition 73 

(s)     Lymphnodes 74 

(6)  Bones  and  joints 74 

(7)  Muscles 74 

(8)  Temperature 75 

(9)  Pulse 75 

(10)     Respiration 76 

c.  The  Head 77 

(i)     The  cranium 77 

(2)  The  facies 78 

(3)  The  eyes 79 

(4)  The  nose 79 

(5)  The  mouth 80 

(6)  The  throat 81 

(7)  The  nasopharynx 82 

(8)  The  larynx 83 

(9)  The  ear 83 

(10)     The  neck 83 

d.  The  Chest 84 

(i)     Inspection 84 

(2)  Palpation 85 

(3)  The  thymus ' 85 

e.  The  Heart 85 

(i)     Inspection 85 

(2)  Palpation 85 

(3)  Percussion 86 

(4)  Auscultation 86 

f .  The  Lungs 87 

(i)     Inspection 87 

(2)  Palpation 87 

(3)  Percussion 87 

(4)  Auscultation 90 

g.  The  Abdomen 93 

(i)     Inspection 93 

(2)  Palpation 94 

(3)  The  stomach 95 

(4)  The  liver 95 

(5)  The  spleen 95 

(6)  The  kidneys 96 

(7)  The  bladder 96 

(8)  The  external  genitals 97 

(9)  The  anus 97 

(10)     The  rectum 97 

h.     The  Extremities 97 

(i)     The  limbs 97 

(2)     The  spine 99 


Contents  ix 

III. — Symptomatology  and  Diagnosis — Continued. 

The  Physical  Examination — Continued.  page 

i.     The  Nervous  System 99 

(i)     Testing  the  mental  condition 99 

(2)  Paralysis  and  spasm 99 

(3)  The  reflexes 100 

(4)  Special  signs loi 

(s)     Sensation 104 

(6)     The  special  senses 104 

Special  Methods  of  Examination 105 

a.  Lumbar  Puncture 105 

b.  Thoracentesis 108 

c.  Exploratory  Puncture  of  the  Peritoneal  Cavity 108 

d.  Exploratory  Puncture  of  the  Pericardial  Cavity 109 

e.  Examination  of  Gastric  Capacity 109 

1.     Examination  by  Duodenal  Catheter 109 

g.     The  Electrical  Reactions 109 

h.     Laryngoscopy no 

i.     Ophthalmoscopy no 

j      Rectal  Examination no 

k.     Roentgen  Ray  Examination no 

Laboratory  Methods  of  Diagnosis no 

a.  The  Urine 112 

b.  The  Blood n8 

c.  The  Stools 125 

d.  The  Cerebrospinal  Fluid 13° 

e.  Exudates  and  Transudates 134 

f .  The  Vaginal  Discharge 136 

g.  The  Sputum 136 

h.     The  Gastric  Contents 138 

i.     The  Widal  Reaction  for  Typhoid 138 

j.     The  von  Pirquet  Test  for  Tuberculosis 139 

k.     The  Wassermann  Reaction  for  Syphilis 140 

1.     The  Schick  Test  for  Immunity  in  Diphtheria ■ 141 

m.     Throat  Cultures 142 

n.     Blood  Cultures 142 

o.     The  Phenolsulphonephthalein  Test  of  Renal  Function 143 

Differential  Diagnosis i43 

IV. — Prognosis  in  Early  Life i45 

V. — Treatment i47 

General  Principles i47 

Special  Indications  in  Early  Life 148 

Specific  Treatment 148 

a.  Serum  Therapy i49 

b.  Vaccine  Therapy 151 

c.  Drugs •  153 

Hygienic  Treatment T-S3 

Dietetic  Treatment i54 

Symptomatic  Treatment i54 

Therapeutic  Measures  Other  than  Drugs i55 

a.    Heat  and  Cold i5S 

(i)     The  ice  bag i5S 

(2)  The  hot  pack i55 

(3)  The  hot  air  bath i5S 


X  Contents 

V. — Treatment — Continued.  page 

b.  Hydrotherapy ' 155 

(i)     The  hot  bath 155 

(2)  The  tepid  bath 156 

(3)  The  cold  sponge 156 

c.  Counterirritation 157 

(i)     Mustard  paste 157 

(2)  The  mustard  pack 157 

(3)  The  turpentine  stupe 157 

(4)  Dry  cupping 157 

(5)  Bleeding 157 

d.  Irrigations  and  Sprays 157 

(i)     Irrigation  of  the  colon 157 

(2)  Gastric  lavage 159 

(3)  Irrigation  of  the  nose 161 

(4)  Spraying  the  nose  and  throat i6r 

(5)  Gargles 161 

(6)  Syringing  the  mouth  and  pharynx 161 

(7)  Irrigation  of  the  ears 160 

e.  Inhalations 162 

f .  Enemata 162 

(i)     Cleansing  enemata 162 

(2)  Nutrient  enemata 162 

(3)  Stimulant  enemata 163 

g.  Gavage  and  Nasal  Feeding , 163 

h.     Massage 163 

i.     Hypodermoclysis 164 

j.     Intravenous  Injections 165 

Useful  Drugs  in  Infancy  and  Childhood 167 

a.  List  and  Description 167 

b.  Table  of  Dosage 167 

c.  Methods  of  Administration 167 

The  Routine  Treatment  of  an  Acute  Self-limited  Disease 180 

The  Routine  Treatment  of  Chronic  Diseases 183 

DIVISION  III 

DISEASES  OF  THE  NEWBORN 

I. — Malformations 184 

II. — Traumatic  Conditions 184 

Caput  Succedaneum 184 

Cephalhematoma 185 

Hematoma  of  the  Sterno-Cleido-Mastoid  Muscle 186 

Intracranial  Hemorrhage 186 

Obstetrical  Paralysis '. 189 

III. — Non-Traumatic  Mechanical  Disturbances 194 

Umbilical  Hernia i94 

Prolapse  of  Meckel's  Diverticulum 196 

IV. — New  Growths 107 

Umbilical  Granuloma i97 

Naevus i97 

V. — Functional  Disturbances i99 

Congenital  Pulmonary  Atelectasis i99 

Hemorrhagic  Disease  of  the  Newborn 202 


Contents  xi 

V — Functional  Disturbances — Continued  page 

Icterus  Neonatorum 212 

Congenital  Cirrhosis  of  the  Liver;  Congenital  Obliteration  of  the  Bile 

Ducts 214 

Sclerema 218 

Edema 219 

VI. — Infections 221 

Infectious  Disease  of  the  Newborn 221 

Ophthalmia  Neonatorum 225 

Tetanus  Neonatorum 227 

Dermatitis  Exfoliativa 228 

Infectious  Haemoglobinuria  (Winckel's  Disease) 229 

VII. — Premature  Infants 231 

DIVISION  IV 

FEEDING 

I. — General  Principles 239 

The  Mammary  Gland 240 

II. — Maternal  Feeding 243 

Human  Milk 243 

a.  Physical  Characteristics 243 

b.  Chemical  Composition 244 

c.  Variations  in  Milk 245 

d.  Colostrum 246 

e.  Daily  Quantity  of  Milk 248 

f .  Bacteriology 249 

g.  Conditions  Affecting  Lactation 249 

Maternal  Nursing 250 

a.  Normal  Maternal  Conditions 250 

b.  Contraindications  for  Breast  Feeding 250 

c.  Sucking 250 

d.  Care  of  the  Breasts 251 

e.  Nursing  the  Newborn ^ 252 

f.  Management  of  Normal  Nursing 253 

g.  Hygiene  of  the  Nursing  Mother 255 

Disturbances  of  Breast  Feeding 257 

a.  Causes 257 

b.  Symptoms  and  Diagnosis •  258 

c.  Management  of  Disturbed  Breast  Feeding 259 

Wet-Nursing 262 

Weaning 264 

III. — Artificial  Feeding 266 

Preliminary  Considerations 266 

Source  of  Food 267 

a.  Requirements •  267 

b.  Cow's  Milk 267 

(i)    The  cow 267 

(2)  Composition  of  cow's  milk 267 

(3)  Bacteriology 269 

(4)  Certified  milk 270 

c.  Sterilization  and  Pasteurization 271 

(i)     Effect  of  heat  on  bacteriology 271 

(2)     Effect  of  heat  on  composition 272 


xii  Contents 

III — Artificial  Feeding — Continued 

Sterilization  and  Pasteurization — Continued  page 

(3)  Effect  of  lieat  on  digestibility 272 

(4)  Sterilization  or  pasteurization 273 

(5)  Indications  for  pasteurization 274 

(6)  Technique  of  pasteurization 274 

d.     The  Examination  of  Milk 275 

(i)     The  fat 275 

(2)  The  protein 276 

(3)  The  carbohydrate  and  salts 277 

(4)  Microscopic  examination 277 

The  Modification  of  Cow's  Milk 277 

a.  Sources  of  Difficulty  in  Artificial  Feeding 277 

b.  Caloric  Requirements  and  Digestive  Requirements '. 279 

(i)     Minimum  caloric  requirements 280 

(2)  Protein  requirements 280 

(3)  Caloric  requirements  as  a  basis  for  feeding 280 

(4)  Digestive  requirements .  281 

(5)  Value  of  caloric  estimation 281 

c.  Percentage  Feeding 282 

d.  The  Modification  of  Cow's  Milk — Theory 283 

(i)     Milk  and  cream  dilution 284 

(2)  Starch;  cereal  diluents 286 

(3)  The  alkaUes;  lime  water,   sodium  bicarbonate,   and 

sodium  citrate 286 

(4)  Peptonization 288 

(5)  Whey  mixtures;  the  split  protein 289 

(6)  Maltose,  dextri-maltose,  and  cane  sugar 291 

(7)  Lactic  acid  milk 292 

(8)  Precipitated  casein .' 293 

(9)  Cooking ; 294 

(10)  Homogenized  fat 295 

(11)  Albumin  milk 295 

(12)  Malt  soup 297 

How  the  Resources  of  Cow's  Milk  Modifications  are  Realized  in  Practice  298 

a.  Prerequisites 298 

b.  The  Patent  Foods 299 

c.  Milk  Laboratories 299 

d.  Home  Modification 3°''- 

(i)     Technique 302 

(2)     Calculation 3°3 

e.  Laboratory  Feeding  and  Home  Modification — Relative  Advan- 

tages and  Disadvantages 3^^^ 

f.  Calculation  of  the  Calories 3^7 

g.  Calculation  of  Percentage  Composition  in  a  Food  of  Known 

Ingredients 3^^ 

The  Practical  Management  of  Artificial  Feeding 321 

a.  General  Principles 321 

(i)     Ends  to  be  attained 321 

(2)  Conditions  of  the  problem 322 

(3)  General  conduct  of  artificial  feeding 322 

b.  The  Feeding  of  Normal  Infants 323 

(i)     Quantity  of  food • 324 

(2)     Intervals  between  feedings 32S 


Contents  xiii 

III — Artificial  Feeding — Continued 

The  Feeding  of  Normal  Infants — Continued  page 

(3)  Percentage  formulae  for  starting  average  well  babies.  326 

(4)  Percentage  formulae  for  feeding  average  well  babies. .  328 

(5)  Increasing  the  strength  of  the  food 328 

c.  The  Feeding  of  Infants  Having  Difficulties  of  Digestion 329 

(i)     Causes  of  digestive  disturbance 329 

(2)  Symptoms  of  digestive  disturbance 329 

(3)  Clinical  types  of  disturbance  seen  in  artificial  feeding.  330 

(4)  Vomiting  cases 330 

(5)  Undigested  movements 331 

(6)  Green  or  discolored  movements 332 

(7)  No  symptoms 332 

d.  The  Feeding  of  Difficult  Cases 333 

e.  Clinical  Indications  for   the  Various   Methods  of  Modif^-ing 

Cow's  Milk 334 

f.  Inability  or  Refusal  to  Take  Food  From  the  Bottle 337 

IV. — Feeding  in  the  Second  Ye.ar 339 

Feeding  of  Healthy  Infants 339 

a.  Weaning  From  the  Bottle 341 

b.  Preparation  of  Foods 341 

c.  Diet  From  the  Twelfth  to  the  Fifteenth  Month 342 

d.  Diet  From  the  Fifteenth  to  the  Eighteenth  Month 343 

e.  Diet  From  the  Eighteenth  to  the  Twenty-fourth  Month 344 

Feeding  in  Difficult  Cases 345 

V. — Feeding  After  the  Secont)  Year 347 

DIVISION  V 

diseases  of  the  g.astro-enteric  tract 

Class  fication 349 

I. — ^Malformations 351 

II. — Traumatic  Mechanical  Injuries 353 

Foreign  Bodies 353 

"Hair  Ball"  in  the  Stomach 354 

Corrosive  Gastritis 354 

III. — Mechanical  Conditions  of  Internal  Origin 356 

Hypertrophic  Stenosis  of  the  Pylorus 356 

Spasm  o   the  Pylorus 367 

D  latat'on  of  the  Stomach 370 

Contraction  of  the  Stomach 373 

Dilatation  and  Hypertrophy  of  the  Colon 374 

Intussusception 377 

Volvulus f 380 

Hernia 380 

Fissure  of  the  .\nus 381 

Hemorrhoids 381 

Prolapse  of  the  Rectum 381 

IV. — New  Growths 383 

V. — Nervous  Disturbances 384 

Nervous  Diarrhea 384 

Nervous  Vomiting 386 


xiv  Contents 

PAGE 

VI. — DiSTUKBANCES  OF  DIGESTION 388 

General  Considerations 388 

a.  Etiology 388 

b.  Pathology 392 

c.  Classification 394 

d.  Symptomatolog}'' 398 

e.  Diagnostic  Methods 399 

f .  General  Treatment 399 

Indigestion  from  an  Excess  of  Food 402 

Indigestion  from  an  Excess  of  Fat 407 

Indigestion  from  an  Excess  of  Carbohydrate 422 

Indigestion  from  an  Excess  of  Protein 433 

Indigestion  from  an  Excess  of  Mineral  Salts 440 

Indigestion  with  Fermentation 442 

VII. — Infections 457 

Infectious  Diarrhea 457 

Summary  of  the  Diarrheas  and  Disturbances  of  Digestion 481 

Problems  and  Research  in  Diseases  of  the  Digestive  Tract 484 

Cholera  Infantum 485 

Gastritis 488 

Proctitis 490 

Appendicitis 49 

VITI. — Unclassified  Diseases 496 

Constipation 496 

Incontinence  of  Feces 505 

Intestinal  Worms 505 

LIST     OF     ILLUSTRATIONS 

PLATE                                            COLORED    PLATES  page 

XV. — The  blood  in  infancy  and  childhood 120 

II. — Icterus  neonatorum 213 

FIG.                                   FULL    PAGE    ILLUSTRATIONS  page 

19. — Position  for  examination  of  the  ears 83 

21.— Normal  areas  of  dulness  to  percussion  of  the  front  of  the  chest 86 

23. — Boundaries  of  the  lobes  of  the  lungs  from  in  front 89 

27. — Proper  method  of  palpating  the  spleen 96 

28. — Examination  of  the  flexibility  of  the  spine 99 

SS- — Lumbar  puncture 107 

35. — Obtaining  urine  from  the  male  infant 113 

40- — Scarifying  for  the  von  Pirquet  tuberculin  test 139 

44- — Gastric  lavage,  first  step .^ .  159 

45. — Gastric  lavage,  second  step 161 

46. — Gastric  lavage,  third  step '. 163 

49- — Tube  feeding,  first  step 167 

SO. — Tube  feeding,  second  step 169 

68. — Incubator  bed  for  premature  infant 232 

69. — Articles  for  premature  infant 234 

70. — Premature  infant  in  incubator  bed 236 

81. — Congenital  atresia  of  the  intestine 351 

82. — Pyloric  stenosis  with  complete  occlusion,  roentgenogram , 359 

83. — Pyloric  stenosis  with  partial  occlusion,  roentgenogram 360 


Contents  xv 

FIG.  PAGE 

84. — Pyloric  stenosis  with  partial  occlusion,  roentgenogram 361 

85. — Pyloric  stenosis  with  partial  occlusion,  roentgenogram 362 

86. — Pyloric  stenosis  with  partial  occlusion,  roentgenogram 363 

94. — Hirschprung's  disease,  roentgenogram 376 

95. — Hirschprung's  disease,  roentgenogram 377 

99. — Follicular  inflammation  of  the  intestine 461 

100. — Follicular  ulceration  of  the  colon 462 

loi.— Colitis 463 

102. — Follicular  ulceration  of  the  colon 464 

103. — Follicular  colitis 465 

104. — Pseudomembranous  colitis 466 

105. — Ulcerative  colitis 467 

106. — Ulcerative  ileo-colitis 468 

FIG.  ILLUSTRATIONS    IN    THE    TEXT  page 

I. — Stomach,  natural  size 7 

2. — Five  periods  of  development  in  the  first  dentition 10 

3. — Eight  periods  of  development  in  the  second  dentition 12 

4. — Normal  infant  seven  months  old 14 

5. — Normal  development  at  six  years 15 

6. — Normal  development  at  twelve  years 16 

7. — Respiration  at  birth 21 

8. — Section  of  fetal  lung  at  five  months, — section  of  infant's  lung  at  ten  months .  30 

9. — Clothing  for  an  infant 39 

10. — Clothing  for  an  infant 39 

1 1 . — Clothing  for  an  infant 4° 

12. — Clothing  for  an  infant 4° 

13. — Infant's  bed.  Infants'  Hospital 51 

14. — Proper  position  for  the  child  when  examined  in  a  sitting  position 69 

15. — Method  of  holding  an  infant  for  examination  of  the  back  of  the  chest 70 

16. — ^^Position  for  examination  of  the  throat 71 

17. — Method  of  holding  an  infant  for  examination  of  the  mouth  and  throat 72 

18. — Obtaining  pulse  rate  in  infants 75 

20. — Examination  for  rigidity  of  the  neck 88 

22. — Percussion  of  the  front  of  the  chest 84 

24. — Boundaries  of  the  lobes  of  the  lungs  from  behind : 89 

25. — Percussion  of  the  back  of  the  chest 90 

26. — Percussion  of  the  apex  of  the  lungs •  91 

29. — Testing  the  knee-Jerks loi 

30. — Examination  for  Kernig's  sign 102 

31. — Examination  for  Brudzinski's  neck  sign 103 

32.- — Position  for  lumbar  puncture 106 

34. — Normal  roentgenogram,  infant  six  months  old m 

36. — Apparatus  for  obtaining  urine  from  a  female  infant ii'3 

37. — Method  of  collecting  urine  from  a  female  infant 113 

38. — Catheterization  of  a  female  infant 114 

41. — Obtaining  blood  for  the  Wassermann  reaction  from  the  longitudinal  sinus  of 

an  infant 140 

42. — Injecting  diphtheria  toxin  for  the  Schick  reaction 141 

43. — Irrigation  of  the  colon 158 

47. — Irrigation  of  the  ear 160 

48. — Irrigation  of  the  no?e 161 

51. — Nasal  feeding 164 


xvi  Contents 

riG.  PAGE 

52. — Intravenous  injections  in  infancy — tapping  the  cerebral  ventricles 165 

53. — Intravenous  injection  in  infancy 166 

54. — Caput  succedaneum 184 

55. — Double  cephalematoma 185 

56. — Characteristic  position  of  the  arm  in  obstetrical  paralysis 190 

57. — Obstetrical  parah'sis 192 

58. — Large  umbilical  hernia i94 

59. — Adhesive  strap  for  umbilical  hernia 195 

60. — Naevus  of  the  face  and  neck 198 

61. — Complete  congenital  atelectasis  of  the  left  lung.     H3'pertrophy  of  the  heart. .  200 

62. — Dr.  Beth  Vincent's  apparatus  for  transfusion 207 

63. — Obtaining  blood  in  parraffin  treated  tube  from  the  donor  in  transfusion 208 

64. — Transfusion  in  the  newborn 208 

65. — Congenital  cirrhosis  of  the  liver 214 

66. — Congenital  cirrhosis  of  the  liver 215 

67. — Infant  premature  at  the  seventh  month 231 

71. — Feeder  for  premature  infants ■  234 

72. — Colostrom  milk 47 

73. — Breast  pump 251 

74. — Sterilizer  and  thermometer 275 

75  — Babcock  fat  tester 276 

76. — Apparatus  for  homogenizing  fat  for  infant  feeding 294 

77. — Walker-Gordon  laboratory  prescription  blank 301 

78. — Home  modification  of  cow's  milk — apparatus 302 

79. — Home  modification  of  cow's  milk — obtaining  the  cream 303 

80. — Home  modification  of  cow's  milk — mixing  the  ingredients 304 

87. — Apparatus  for  estimating  gastric  retenfon  time 360 

88  — Aspiration  of  the  gastric  contents 361 

89. — Dilated  stomach ■ 37i 

90. — Dilatation  of  the  stomach 372 

91. — Hirschprung's  disease — section  through  colon 374 

92. — Congenital  dilatation  of  the  colon • 375 

93. — Dilatation  of  the  colon 37^ 

96. — Worsted  truss  for  nguinal  hernia 380 

97. — Infantile  atrophy 4i4 

98  — Infantile  atrophy 4iS 

107  — Oxyuris  vermicular  s.     Ascaris  lumbricoides 5^7 

108. — Taenia SOQ 


DIVISION  I 

THE  NORMAL  CHILD 

I.     INTRODUCTION 

Pediatrics  is  a  branch  of  medicine  the  importance  of  which  as  a 
special  study  has  gradually  come  to  be  more  and  more  generally 
recognized.  It  has  become  a  specialty,  partly  from  the  same  causes 
which  have  led  to  the  great  increase  in  specialization  in  all  branches 
of  medicine,  but  more  particularly  because  of  the  great  number  of 
peculiarities  inherent  in  the  manifestations  of  disease  in  early  life. 
From  the  very  beginning,  the  diagnosis  and  treatment  of  disease 
in  infants  and  young  children  is  attended  by  difficulties  not  encoun- 
tered with  adult  patients.  These  young  patients  can  give  no  ade- 
quate description  of  their  subjective  symptoms,  and  the  physician 
must  rely  on  intimate  and  profound  knowledge  of  the  ways  of  young 
children,  which  can  only  be  gained  by  long  observation,  if  he  will 
read  aright  the  manifestations  before  him.  Moreover,  the  most 
thorough  knowledge  of  normal  and  abnormal  conditions,  if  gained 
wholly  from  observation  of  adult  patients,  is  of  little  value  in  chil- 
dren, because  of  the  difference  in  the  normal  standard.  Not  only 
are  all  the  standards  by  which  deviations  from  the  normal  are  recog- 
nized different  from  those  of  adults,  but  there  is  a  different  standard 
for  each  age.  Manifestations  which  are  normal  at  one  age,  are 
abnormal  at  another,  and  even  the  anatomic  lesions  of  disease  are 
seen  to  be  modified  in  the  various  stages  of  the  child's  development. 
Young  human  beings  must  be  regarded,  throughout  their  early  life, 
as  incomplete.  Growth  is  not  merely  increase  in  size,  but  it  is  a 
continuous  process  of  anatomical  and  functional  development,  which 
is  not  completed  until  some  time  after  the  age  of  puberty.  In  early 
life,  arrest,  or  retardation  of  the  process  of  normal  development 
may  in  itself  constitute  a  disease  picture;  developmental  conditions 
form  an  important  division  in  the  etiology  of  disease  in  childhood, 
but  play  no  part  after  adult  life  is  reached. 

The  incompleteness  of  the  child's  development  plays  a  still  greater 
role  in  those  actual  diseases  which  are  produced  by  conditions  out- 
side the  body.  It  may  be  true  that  the  same  diseased  conditions 
are  seen  in  childhood  and  in  adult  Hfe.  But  their  manifestations  are 
greatly  modified  by  the  incompleteness  of  the  child's  development, 
and  often  vary  even  with  the  different  ages  of  childhood.     Even  the 


2  The  Normal  Child 

reaction  to  treatment  dilTers  in  the  different  stages  of  development. 
The  rules  laid  down  for  the  diagnosis  and  treatment  of  these  diseases 
common  both  to  childhood  and  to  adult  Hfe,  if  gained  by  a  study 
of  adults,  cannot  hold  for  children. 

There  is  further  need  for  special  study  and  training  in  pediatrics. 
Children,  in  addition  to  being  liable  to  most  of  the  diseases  seen  in 
adults,  have  also  a  group  of  diseases  which  are  entirely  their  own. 
Here  again,  the  fundamental  cause  lies  in  their  uncompleted  develop- 
ment, through  which  conditions  acting  upon  their  bodies  from  the 
outside  w^orld,  which  can  have  no  injurious  effect  upon  the  com- 
pleted adult,  have  a  very  injurious  effect  upon  the  young,  unde- 
veloped child.  These  young  human  beings,  at  each  stage  of  devel- 
opment, have  their  own  peculiarities  of  resistance  or  lack  of  resist- 
ance to  these  conditions.  Their  treatment  must  be  modified  at  all 
times,  to  correspond  to  their  age,  and  stage  of  development.  The 
high  rate  of  infant  mortality  is  still  one  of  the  greatest  problems  of 
medicine.  It  is  due  primarily  to  no  other  cause  than  the  lack  of 
resistance  to  the  conditions  of  its  surroundings  which  exists  in  the 
undeveloped  infant.  Its  existence  is  alone  sufficient  to  point  to 
the  need  for  a  special  study  of  the  pathology  of  early  life. 

The  fundamental  requisite  in  recognizing  the  abnormal,  is  a 
thorough  knowledge  of  the  normal.  In  pediatrics,  a  thorough  un- 
derstanding of  normal  conditions  at  every  stage  of  development  is 
essential.  The  distinction  between  infancy  and  childhood  is  neither 
so  artificial  nor  so  arbitrary  as  it  seems  at  first..  At  about  the  age 
of  two  years,  certain  very  important  processes  of  anatomical  and 
functional  development  become  completed.  The  incompleteness  of 
these  functions  in  the  first  two  years  has  been  an  important  source 
of  difliculty,  and  a  cause  of  abnormahty,  which  later  are  no  longer 
seen.  Hence  we  refer  to  the  first  two  years  as  infancy,  and  to  the 
later  years  as  childhood.  The  distinctive  fine  between  childhood  and 
adult  life  is  much  harder  to  draw.  It  is  difficult  to  say  at  just  what 
age  normal  development  is  finally  completed,  but  the  period  is  arbi- 
trarily placed  at  the  age  of  puberty.  From  birth  to  the  age  of 
puberty,  then,  is  the  period  through  which  the  development  of  the 
normal  child  must  be  studied. 


II.     THE  INFANT  AT  TERM 

A  normal  infant  at  birth  has  a  reddened  skin,  and  is  covered 
thickly  in  many  parts  by  the  vernix  caseosa,  which  is  removed  by 
the  first  bath.  The  description  of  the  newborn  infant  will  be  given 
in  two  divisions.  The  first  will  be  a  description  of  a  complete 
physical  examination  of  a  normal  infant  at  birth,  in  the  form  in 
which  physical  examinations  are  usually  recorded  in  case  histories. 
The  second  division  will  be  a  description  of  certain  features  of  the 
infant's  internal  structure,  in  the  form  in  which  they  are  recorded 
in  records  of  post-mortem  examinations.  This  form  of  description 
will  afford  the  student  a  standard  of  comparison  by  which  he  may 
recognize  at  once  the  abnormal,  both  in  physical  examination,  and 
in  pathological  anatomy. 

THE  PHYSICAL  EXAMINATION 

The  baby  appears  well  nourished,  the  body  and  limbs  are  well 
rounded,  the  cry  is  vigorous,  the  extremities  are  warm,  and  the 
grasp  of  the  hands  is  strong  and  vigorous.  The  skin  is  usually  clear, 
but  may  be  somewhat  mottled,  and  is  some  shade  of  delicate  pink. 
The  eyes  are  half  open  when  the  baby  is  awake,  and  are  expres- 
sionless, of  a  dull  grayish-blue  color.  The  spine  is  very  flexible, 
and  can  be  twisted  and  bent  at  will  in  any  direction.  The  neck 
appears  short. 

HEAD  — The  head  appears  large  in  proportion  to  the  body,  while 
the  face  is  quite  small  in  proportion  to  the  cranium.  The  length 
and  thickness  of  the  hair  is  very  variable.  The  cranium  may  be 
somewhat  distorted  by  the  pressure  of  birth,  but  these  abnormal 
appearances  pass  away  in  a  few  months.  An  average  circumference 
of  the  cranium  at  birth  is  t^t,  cm.  (13  in.).  The  anterior  fontanelle 
may  be  somewhat  depressed  immediately  after  birth,  but  is  soon 
on  a  level  with  the  bones.  Its  size  is  variable,  but  the  measurements 
are  usually  2  to  3  cm.  in  length,  by  about  2  cm.  in  width.  The 
frontal  suture  is  usually  open  in  its  upper  part,  and  the  posterior 
fontanelle,  while  open,  is  often  obliterated  by  overlapping  of  the 
bones. 

MOUTH  AND  THROAT.— The  mucus  membrane  of  the  mouth 
is  of  a  clear  pink.  The  tongue  is  slightly  coated,  and  comparatively 
dry.  The  gums  do  not  completely  meet.  The  soft  palate  runs 
backward  almost  horizontally,  descending  much  less  than  in  the 
adult.     The  uvula  is  rudimentary. 


4  The  Normal  Child 

THE  EAR. — The  meatus  passing  inward,  inclines  downward,  and 
the  membranum  tympani  is  almost  horizontal,  so  that  its  inspection 
is  difficult. 

THORAX.^ — The  thorax  presents  a  very  different  appearance  from 
that  of  the  adult.  It  is  much  smaller  in  proportion  to  the  head 
and  abdomen,  forming  the  upper  and  smaller  portion  of  the  egg- 
shaped  trunk.  Its  whole  shape  presents  a  peculiar  appearance, 
which  is  accentuated  by  the  small  shoulders.  The  sternum  is  rela- 
tively much  smaller  than  that  of  the  adult  male,  and  its  top  is  placed 
relatively  higher,  while  the  sides  of  the  thorax  are  relatively  shorter 
than  in  the  adult.  The  ribs  are  more  nearly  horizontal,  and  their 
borders  diverge  relatively  rapidly.  The  transverse  diameter  is 
shorter  in  proportion  to  the  antero-posterior. 

THYMUS. — The  thymus  is  present  and  well  developed  at  birth, 
but  its  outline  cannot  be  clearly  distinguished  by  percussion. 

HEART. — The  impulse  is  visible  and  palpable  rather  higher  and 
nearer  to  the  mammary  line  in  the  infant  than  in  the  adult.  The 
entire  position  of  the  cardiac  dulness  is  higher  in  proportion  to  the 
chest  walls.  The  infant's  heart  is  less  covered  by  the  lungs  than 
is  the  adult's.  The  superficial  dulness  lies  between  the  left  border 
of  the  sternum  and  the  mammary  line,  and  the  entire  area  can  easily 
be  covered  by  the  tip  of  the  finger  used  in  percussing.  The  upper 
border,  and  the  relative  dulness  are  difficult  to  determine.  The 
heart  sounds  are  still  largely  of  the  fetal  type,  the  diastolic  pause 
being  absent,  and  the  first  sound  being  much  like  the  second.  The 
rhythm  is  regular.  Murmurs  are  frequently  present  at  birth,  with- 
out any  abnormal  significance;  only  their  persistence  should  attract 
attention. 

LUNGS. — The  lungs  are  resonant  to  percussion,  but  at  birth  the 
resonance  is  less  than  in  later  life.  The  respiratory  murmur  is  loud 
and  harsh. 

ABDOMEN. — The  abdomen  is  large  in  proportion  to  the  thorax. 
Its  physical  examination  differs  from  that  of  the  normal  adult  only 
in  one  important  particular,  namely,  in  the  relatively  large  size  of 
the  liver.  Its  border  is  felt  fully  2  cm.  below  the  edge  of  the  ribs 
in  the  right  epigastric  and  hypochondriac  regions,  and  its  upper 
border  of  dulness  encroaches  on  the  resonance  of  the  right  lung  to 
the  extent  of  fully  one  rib  and  interspace.  The  dull  area  of  the 
spleen  is  rarely  perceptible,  but  when  found  corresponds  to  that 
of  the  adult.  The  border  is  not  normally  palpable.  The  bladder 
is  an  abdominal  rather  than  a  pelvic  organ,  but  normally  gives  no 
dulness  in  a  newborn  infant. 


The  Infant  at  Term  5 

TESTICLES. — The  testicles  are  normally  found  in  the  scrotum. 

LIMBS. — The  limbs  are  well  formed,  and  present  no  features  of 
particular  note  in  newborn  infants.  The  grasp  of  the  hands  is  re- 
markably strong.  The  feet  appear  flat,  but  this  apparent  flatness 
is  due  to  a  pad  of  fat  tissue,  and  not  to  any  flattening  of  the  arch. 

HEIGHT  AND  WEIGHT.— The  height  and  weight  are  variable. 
The  average  height  of  a  newborn  male  infant  is  49.5  cm.  (igf  in.); 
in  the  female  it  is  48.5  cm.  (19^  in.).  The  weight  is  still  more 
variable  than  the  height.  The  average  weight  for  males  is  about 
3,520  grammes  (7!  pounds),  and  for  females  is  about  3,290  grammes 
(7 J  pounds). 

THE  SPECIAL  SENSES.— Although  at  birth  the  eye  is  anatom- 
ically perfect,  visual  perception  is  not  developed.  Hearing  appears 
dull  during  the  first  few  days  of  life.  The  sense  of  touch  is  well 
developed.  No  satisfactory  conclusions  can  be  drawn  as  to  taste 
and  smell. 

The  newborn  infant  passes  very  little  urine.  He  does  not  usually 
perspire.  He  cannot  cry  tears.  He  can  have  a  movement  of  the 
bowels,  which  consists  of  meconium.  Meconium  is  inodorous,  viscid, 
slightly  acid,  and  of  a  brownish-black  color.  It  consists  of  bile 
constituents  and  intestinal  secretions,  and  contains  mucus,  epithelium, 
and  fat  drops  from  the  vernix  caseosa.     At  birth,  it  is  sterile. 


INTERNAL  STRUCTURE 

Among  the  features  in  the  anatomy  of  the  newborn  infant  which 
cannot  be  perceived  by  ordinary  physical  examination,  only  those 
will  be  described  which  present  essential  differences  from  those  of 
adults. 

BRAIN. — The  brain  of  the  newborn  infant  is  proportionately  very 
much  larger  than  in  the  adult. 

THE  NASO-PHARYNX.— The  nasal  cavity  is  relatively  long  and 
shallow,  and  its  respiratory  portion  is  very  narrow.  The  opening 
of  the  posterior  nares  is  relatively  very  small.  The  naso-pharynx 
is  simply  a  narrow  passage  running  obliquely  backward  and  down- 
ward from  the  constricted  opening  of  the  posterior  nares.  The  lym- 
phoid tissue  on  the  posterior  wall  of  the  pharynx  is  well  developed, 
and  much  richer  in  absorbents  than  are  the  faucial  tonsils.  The 
openings  of  the  eustachian  tubes  are  opposite  a  higher  part  of  the 
nose  than  in  the  adult,  although  their  direction  is  more  horizontal. 
The  ends  of  their  cartilages,  which  make  such  prominent  folds  in 
the  adult,  are  not  developed,  so  that  these  prominences  do  not  exist. 


6  The  Normal  Child 

TEETH. — There  are  at  birth  twenty  embryo  teeth,  ten  in  each 
jaw,  enveloped  in  their  tooth  sacs. 

EAR. — The  development  of  the  ear  in  its  several  parts  is  very 
unequal  at  birth.  The  structures  of  the  internal  ear  and  of  the 
tympanic  cavity  are  fully  formed  at  birth,  while  the  external  audi- 
tory meatus  is  very  different  in  its  development  from  that  of  later 
life.  The  mastoid  antrum  exists  at  birth,  but  the  cells  are  wholly 
undeveloped. 

THYMUS  GLAND.— The  thymus  gland  exists  at  birth,  is  well 
developed,  and  lies  partly  above,  and  partly  in  front  of  the  heart. 

HEART. — The  anatomy  of  the  heart  at  birth,  and  the  changes 
in  the  circulation  which  take  place  shortly  after  birth,  are  so  inti- 
mately connected  with  the  subject  of  congenital  cardiac  disease,  that 
their  description  will  be  postponed  till  that  subject  is  discussed. 
In  a  baby  dying  immediately  after  birth,  it  would  not  be  abnormal 
to  find  an  open  foramen  ovale,  or  an  open  ductus  arteriosus. 

LUNGS. — ^The  lungs  at  birth  present  a  very  notable  difference 
from  the  lungs  of  older  individuals.  Their  chief  characteristic  is 
their  embryonic  type.  The  alveoH  are  relatively  small  in  size,  and 
their  number  is  small  in  proportion  to  the  bronchioles.  Their  walls 
are  relatively  thick,  and  the  connective-tissue  stroma  is  in  greater 
proportion.  Blood  vessels  are  relatively  abundant,  and  play  a  more 
important  role  than  the  lymphatic  absorbents.  These  conditions, 
while  gradually  diminishing,  persist  to  a  great  extent  throughout 
childhood. 

KIDNEYS. — The  kidneys  and  adrenals  are  of  relatively  large 
size  in  the  newborn  infant.  The  kidneys  are  markedly  lobulated. 
A  prenatal  condition  called  the  uric  acid  infarction  exists  normally 
in  the  kidneys  at  birth.  This  shows  itself  as  an  orange  or  light 
red  deposit  in  the  straight  tubules,  which  cause  these  tubules  to 
appear  prominent  on  section  of  the  organ.  This  deposit  consists 
of  urate  of  ammonia,  amorphous  urates,  uric  acid  crystals,  and 
epitheHal  cells.  The  adrenals  quite  cover  the  tops  of  the  kidneys 
at  birth. 

STOMACH. — The  stomach  at  birth  is  remarkably  small,  and 
more  tubular  than  in  the  adult,  the  fundus  being  but  slightly  devel- 
oped. It  is  consequently  even  more  vertically  placed,  for  it  is  the 
enlargement  of  the  greater  curvature  which  causes  the  later  obliquity 
of  the  stomach'^s  axis.     Its  capacity  is  about  25  to  30  c.c. 


The  Infant  at  Term 

Fig.  I 


^"■" 


Stomach,  natural  size.     Infant  three  hours  old. 
Warren  Museum,  Harvard  University. 

THE  INTESTINE. — The  chief  pecuharity  of  the  intestine  in  new- 
born infants,  is  that  it  is  much  less  fixed  than  in  adult  life.  This 
difference  is  most  striking  in  the  large  intestine,  particularly  in  the 
cecum,  ascending  colon,  and  sigmoid  flexure,  which  show  a  con- 
siderable mesentery.  The  average  length  of  the  small  intestine  is 
287  cm.  (9  ft.  5  in.);  of  the  large  intestine  it  is  56  cm.  (i  ft.  10  in,). 
The  total  variation  may  amount  to  61  cm.  (2  ft.). 


LYMPHATIC  SYSTEM.- 
oped  and  active  at  birth. 


-The  lymphatic  system  is  well  devel- 


BONE  MARROW.— At  birth,  and  indeed,  throughout  the  early- 
months  of  life,  the  bone  marrow  is  red.  The  red  color  is  caused  by 
the  numerous  injected  blood  vessels,  and  is  more  intense  toward  the 
central  portion  of  the  bones. 


III.     NORMAL  DEVELOPMENT 

In  following  the  normal  development  of  the  baby  through  the 
periods  of  infancy  and  childhood,  those  changes  will  be  considered 
first  which  appear  on  physical  examination.  In  a  second  division 
will  be  considered  the  development  of  internal  structure. 

NORMAL  DEVELOPMENT  AS  SEEN  ON  PHYSICAL 
EXAMINATION 

THE  CORD. — By  a  process  of  disintegration  the  cord  separates 
from  the  living  tissues  at  the  umbilicus,  and  falls  off.  This  occurs 
at  about  the  seventh  or  eighth  day.  The  umbilical  scar  normally 
is  always  depressed. 

THE  SPINE. — The  flexibility  of  the  spine  gradually  becomes  less 
as  the  infant  grows  older,  although  it  always  remains  greater  than 
that  of  the  adult  spine.  There  are  at  birth  no  natural  curves  in  the 
spine  except  the  sacral  curve.  As  the  dorsal  curve  is 'a  permanent 
condition,  part  of  the  general  curve  of  the  body,  it  is  the  develop- 
ment of  the  cervical  and  lumbar  curves  which  are  of  interest  from 
the  point  of  view  of  development.  The  cervical  curve  is  produced 
by  the  pull  of  the  muscles  of  the  back  of  the  neck,  when  the  child 
begins  to  raise  its  head.  *  The  child  usually  begins  to  hold  up  its 
head,  only  the  trunk  being  supported,  during  the  fourth  month. 
The  cervical  curve  begins  to  appear  at  about  this  period,  but  is 
never  more  than  a  habitual  position,  as  the  convexity  of  the  front 
of  the  neck  can  always  be  obliterated  by  changing  the  position  of 
the  head.  The  lumbar  curve  is  supposed  to  be  caused  by  the  short- 
ness of  the  ilio-femoral  ligaments.  When  the  child  begins  to  stand, 
these  ligaments  tend  to  incline  the  body  forward,  and  this  tendency 
is  corrected  by  the  contractions  of  the  muscles  of  the  back,  which 
straighten  the  line  of  the  body  by  throwing  forward  the  promon- 
tory of  the  sacrum.  The  lumbar  curve  is  first  observed  when  the 
child  is  one  or  two  years  old,  but  it  is  not  continually  present  till 
some  time  later,  and  it  can  be  obhterated  until  adult  life  is  reached. 

The  surface  anatomy  of  the  spine  in  infancy  and  childhood  pre- 
sents marked  differences  from  that  of  adults.  In  the  infant,  the 
back  is  rounded  from  side  to  side,  the  spine  being  the  center  of  a 
more  or  less  continuous  curve.  The  spinous  processes  are  relatively 
undeveloped,  and  the  laminae  overlap  less,  look  more  directly  back- 
ward, and  are  nearer  the  surface.  At  three  years  of  age  the  spine 
shows  a  great  change  which  has  been  coming  on  since  the  age  of 


Normal  Development  9 

eighteen  months.  The  spinous  processes  now  stand  out  in  a  prom- 
inent row,  and  although  the  laminae  are  still  near  the  surface,  the 
back  is  flatter,  and  there  is  some  appearance  of  a  median  furrow. 
At  six  or  seven  years  the  spine  has  made  much  greater  progress 
toward  the  adult  type,  and  shows  no  important  differences  during 
the  remainder  of    childhood. 

THE  HEAD. — The  head  grows  very  rapidly,  especially  in  infancy. 
The  average  circumference  at  birth  is  t^t,  cm.  (13  inches).  The 
growth  is  most  rapid  during  the  first  year,  the  increase  in  circum- 
ference amounting  to  about  12 'cm.  In  the  second  year  the  increase 
is  2.5  cm.,  and  in  the  next  three  years  it  is  5  cm.  After  the  age  of 
five  years,  the  increase  in  circumference  is  very  slow,  and  only  2 
or  3  cm.  have  been  added  when  adult  life  is  reached.  The  growth 
of  the  thorax  is  so  rapid,  that  the  proportion  of  the  head  to  the 
thorax  becomes  equal  during  the  first  year.  The  table  shows  the 
relative  and  proportional  growth  of  the  head  and  thorax  du  ing 
childhood. 

Table  i 
Circumferences  of  Head  and  Thorax  from  Birth  to  Thirteen  Years 


Birth 33  cm.      (13    inches) 31cm. 

5  weeks 38  cm.      (15    inches) 36  cm. 

5  months 42  cm.      (165  inches) 41  cm. 

9  months 45 . 5  cm.  (18    inches) 43  cm. 

I  year 45.5  cm.  (18    inches) 47.5  cm. 

48  cm.      (19    inches) 51  cm. 

51  cm.      (205  inches) 55  cm. 

53  cm.      (21    inches) 54  cm. 

53  cm.      (21    inches) 54  cm. 

52  cm.      (20I  inches) 55  cm. 

•  ■  54  cm-      (21 J  inches) 54  cm. 

53  cm.      (21    inches) 59  cm. 

54  cm.      (21 J  inches) 61  cm. 

53  cm.      (21    inches) 62  cm. 

56  cm.      (2 2 1  inches) 63  cm. 

•  -  ■  -SS-S  cm.  (2 1 1  inches) 63  cm. 

54  cm.      (2 1 1  inches) 66  cm. 


2 

years 

3 

" 

4 

li 

.s 

u 

6 

If 

7 

11 

8 

li 

0 

u 

10 

a 

II 

u 

12 

u 

1-3 

u 

inches) 
inches) 
inches) 
inches) 
inches) 
inches) 
inches) 
inches) 
inches) 
inches) 
inches) 
inches) 
inches) 
inches) 
24I  inches) 
4f  inches) 


I2t 

i4i 
i6i 
17 
i8| 

20| 
2l| 
2li 
2lf 
2lf 
21J 
23I 
24 

24i 


26 


nches) 


The  posterior  fontanelle  becomes  imperceptible  by  the  sixth  week. 
The  main  sutures  of  the  cranium  are  not  usually  ossified  before  the 
end  of  the  sixth  month.  The  anterior  fontanelle  appears  to  grow 
larger  up  to  the  ninth  month,  and  probably  grows  with  the  head, 
although  becoming  relatively  smaller.  It  appears  to  remain  sta- 
tionary from  the  ninth  to  the  twelfth  month,  and  then  gradually 
becomes  smaller.  Its  average  time  of  closing  is  the  nineteenth  month, 
although  variations  in  the  time  of  closure  extending  from  the  four- 
teenth to  the  twenty-second  months  are  not  abnormal.  An  open 
fontanelle  at  the  end  of  the  second  year  may  be  considered  abnormal. 

The  small  proportion  of  the  size  of  the  face  to  that  of  the  cranium 


10 


The  Normal  Child 


gradually  grows  less.  The  downward  growth  of  the  face  is  one  of 
the  important  features  of  development.  The  table  shows  the  pro- 
portions of  the  face  to  the  cranium  in  the  different  periods  of 
childhood. 

Table  2 

Proportions  of  Face  to  Cranium 

AGE  FACE        CRANIUM 

Early  infancy i       to       8 

2  years i       to       6 

5      "     I  to  4 

10      "     , I  to  3 

Adult  female i  to  25 

Adult  male i  to  2 

THE  TEETH. — At  birth,  the  twenty  embryo  teeth,  enveloped  in 
their  tooth-sacs,  are  so  enclosed  in  the  alveolar  processes  of  the  jaws, 
that  nothing  but  smooth  mucus  membrane  is  apparent  on  the  gums 
above.  When  calcification  of  the  neck  of  the  tooth  begins,  elon- 
gation of  the  tooth  follows,  and  the  tooth  is  so  enclosed  that  growth 
can  only  occur  toward  the  gum,  which  forms  the  point  of  least 
resistance.  This  growth  probably  begins  at  birth.  Pressure  of  the 
crown  of  the  tooth  causes  atrophy  of  the  gum,  and  finally  the  tooth 
pierces  the  mucus  membrane.  The  various  teeth  appear  at  times 
dependent  upon  their  order  of  development,  which  is  fairly 
regular  in  a  normal  infant,  although  variations  in  the  order  and 
time  of  appearance  of  the  teeth  are  so  common,  that  they  cannot 
be  called  abnormal.  The  first  teeth  usually  appear  from  the  sixth 
to  the  eighth  month.  Early  appearance  of  the  teeth  is  never  a 
sign  of  disease,  and  children  have  been  born  with  teeth.  Delayed 
dentition  is  usually  due  to  rachitis,  but  is  seen  in  other  conditions, 


Fig.  2 


Five  periods  of  development  in  the  first  dentition 


Normal  Development  1 1 

such  as  cretinism,  and  defective  cerebral  development.  In  many 
healthy  infants,  no  teeth  are  seen  before  the  tenth  month,  and  den- 
tition may  even  be  delayed  until  the  fourteenth  month  without 
other  evidences  of  any  abnormality.  The  order  of  appearance  of 
the  teeth  is  shown  in  the  table. 

Table  3 

Temporary  Teeth.     First  Detiiition.     Twenty  in  Number 

DENTAL  PERIODS  GROLTS  OF  TEETH 

I.       6  to    8  months 2  middle  lower  incisors 

II.       8  to  10  months 4  upper  incisors 

III.  12  to  14  months 2  lateral  lower  incisors  and 

4  first  molars 

IV.  18  to  20  months 4  canines 

V.     28  to  32  months 4  second  molars 


The  second  dentition  begins  at  about  the  sixth  year.  The  first 
of  the  permanent  teeth  to  appear  are  called  the  sixth-year  molars. 
They  do  not  replace  any  of  the  temporary  teeth,  but  the  jaw  having 
grown  sufficiently  to  provide  more  space,  they  appear  just  back  of 
the  second  molars  of  the  first  set.  In  the  seventh  and  eighth  years 
the  permanent  incisors  replace  those  of  the  temporary  set.  In  the 
ninth  and  tenth  years  the  bicuspids  replace  the  temporary  molars. 
In  the  eleventh  year  the  permanent  cuspids  (canines)  replace  the 
temporary,  and  in  the  twelfth  year  the  four  second  molars  appear. 
This  completes  the  second  dentition  of  childhood,  twenty-eight  teeth, 
the  remaining  four  molars  belonging  to  adult  life. 

Table  4 
Permanent  Teeth.    Second  Dentition.     Thirty-two  in  Number 

YEARS  GROtrPS 

6 4  first  molars 

7 4  middle  incisors 

8 4  lateral  incisors 

9 4  first  bicuspids 

10 4  second  bicuspids 

II 4  canines 

12 4  second  molars 

17  to  25 4  third  molars  (wisdom-teeth) 


12 


The  Normal  Child 

Fig.  3 


8  years 

VflrrfTTT 


Eight  periods  of  development  in  the  second  dentition 

THE  THORAX.— The  thorax,  which  is  insignificant  at  birth, 
grows  rapidly.  The  measurements  showing  the  rate  of  increase  in 
the  circumference  of  the  thorax  are  seen  in  the  table.  The  circum- 
ference of  the  thorax  normally  remains  less  or  equal  to  that  of  the 
head  throughout  infancy.  Not  until  the  third  year  does  the  thorax 
begin  to  show  a  measurement  greater  than  that  of  the  head.  With 
the  growth  in  circumference,  there  occurs  increase  in  the  transverse 
diameter  as  compared  with  the  antero-posterior,  so  that  the  thorax 
graduall}^  assumes  the  elliptical  shape  which  is  characteristic  of  later 
childhood.  At  the  same  time,  the  peculiarities  in  the  shape  of  the 
thorax  which  are  so  notable  at  birth,  disappear,  and  at  about  the 
fifth  year  the  infantile  type  of  thorax  is  no  longer  evident. 

THE  THYMUS.— The  thymus  is  most  developed  during  the  first 
two  years  of  life.     At  no  time,  however,  unless  the  organ  is  notably 


Normal  Development  13 

enlarged,  can  its  dulness  be  distinguished  from  that  of  the  heart 
and  great  vessels. 

THE  HEART. — Most  of  the  changes  in  the  position  of  the  cardiac 
impulse,  and  of  the  precordial  dulness,  which  have  been  described 
as  taking  place  during  the  development  of  the  infant,  are  relative, 
and  are  due  to  pecuHarities  of  the  topography  of  the  chest  wall, 
rather  than  to  changes  in  the  position  of  the  heart.  That  the  car- 
diac impulse  in  infancy  and  early  childhood  is  almost  invariably 
found  not  in  the  fifth,  but  in  the  fourth  interspace,  is  due  to  this 
cause.  In  early  childhood  the  impulse  may  be  found  in  either  the 
fourth  or  the  fifth  interspaces,  while  in  later  childhood  it  is  usually 
in'  the  fifth.  The  relation  of  the  impulse  to  the  nipple  presents 
similar  variations.  In  infancy  and  early  childhood  it  is  usually 
outside  the  mammary  line,  and  cannot  be  considered  abnormal  if 
less  than  2  cm.  beyond  the  nipple.  In  middle  childhood,  the  im- 
pulse is  in  or  near  the  mammary  line.  In  later  childhood  it  is  more 
often  seen  inside  the  nipple,  and  should  always  be  found  in  this 
position  after  the  thirteenth  year. 

An  important  feature  in  the  physical  examination  of  the  heart 
is  seen  in  the  position  of  the  area  of  superficial  or  absolute  cardiac 
dulness  to  percussion.  In  infancy  and  the  latter  part  of  childhood, 
the  right  border  of  absolute  dulness  is,  as  in  the  adult,  at  the  left 
border  of  the  sternum.  In  middle  childhood  it  may  encroach  a  little 
on  the  sternum,  even  as  far  as  its  middle.  The  relative  or  deep 
cardiac  dulness  is  difficult  to  determine  in  young  children.  WTien 
found  it  is  proportionately  larger  than  in  the  adult.  Its  upper 
border  is  at  the  second  interspace,  or  lower  border  of  the  second 
costal  cartilage.  On  the  left  it  extends  to  near  the  mammary  line, 
corresponding  to  the  position  of  the  impulse  at  the  various  ages. 
On  the  right  it  follows  the  right  parasternal  line. 

On  auscultation,  the  diastolic  pause  remains  slight  or  impercept- 
ible throughout  infancy,  and  the  rapidity  of  the  cardiac  action  is 
so  great,  that  it  is  often  difficult  to  distinguish  the  first  from  the 
second  heart  sound.  Normally,  however,  after  the  first  weeks  of 
life,  the  first  sound  becomes  louder  than  the  second,  and  the  cardiac 
cycle  can  be  recognized  from  this.  Murmurs  persisting  after  the 
first  week  of  life,  are  abnormal. 

THE  LUNGS.— The  percussion  note  in  childhood  is  more  tym- 
panitic than  in  the  adult,  especially  under  the  clavicles,  and  in  the 
interscapular  region  behind.  There  may  even  be  cracked-pot  reso- 
nance under  the  right  clavicle,  in  healthy  lungs.  This  tympany  is 
due  to  the  relatively  large  proportion  of  bronchial  to  alveolar  air 
space,  which  persists  throughout  childhood,  although  in  later  child- 
hood, the  lung  gradually  approaches  the  adult  type.     On  ausculta- 


14 


The  Normal  Child 


tion,  the  normal  respiratory  murmur  differs  entirely  from  that  of 
adults.  It  is  of  a  type  generally  described  as  "puerile."  The  breath- 
ing is  rude,  loud,  and  harsh,  and  expiration  is  heard  better  than  in 
adults.  It  is  often  described  as  resembling  the  bronchial  breathing 
of  adults,  but  does  not  resemble  it  except  in  the  terminology  of 
description.  The  difference  cannot  be  described,  being  one  of  quality, 
and  can  only  be   learned  by   experience   and  practice.     It  is  gen- 


Normal  infant  seven  months  old 


erally  stated  that  this  quality  of  the  normal  respiratory  murmur  of 
childhood  is  due  to  the  fact  that  the  sounds  from  the  trachea  and 
large  bronchi  are  heard  more  plainly,  because  they  are  not  trans- 
mitted through  £0  thick  a  layer  of  lung  and  chest  wall.  This  expla- 
nation does  not  seem  to  me  at  all  satisfactory.  If  it  were  true,  the 
sounds  would  have  the  quality  of  bronchial  breathing,  for  we  know 
that  in  both  children  and  adults,  we  are  hearing  in  bronchial  breath- 
ing the  sounds  from  the  trachea  and  large  bronchi,  which  are  trans- 
mitted more  easily  through  solidified  lung.  The  normal  respiratory 
murmur  of  children  has  not  the  so-called  bronchial  quality,     I  believe 


Normal  Development 


15 


its  loud,  harsh  quality  to  be  due  to  the  greater  size  and  number  of 
the  bronchioles  in  the  child's  lung.  In  later  childhood,  this  pecu- 
liarity of  the  breathing  gradually  diminishes  with  the  development 
of  a  greater  proportion  of  alveolar  space,  as  the  lung  approaches  the 
adult  type. 

Fig.  s 


Normal  development  at  six  \'ears 

THE  ABDOMEN. — Throughout  infancy,  the  circumference  of 
the  abdomen  remains  about  the  same  as  that  of  the  chest.  After 
the  age  of  two  years,  the  enlargement  of  the  chest  causes  the  abdomen 
gradually  to  assume  the  adult  proportion.  The  abdominal  walls  in 
childhood  are  thinner,  and  more  easily  relaxed,  than  in  the  adult. 

THE  LIVER. — The  liver  remains  relatively  large  in  infancy  and 
early  childhood.  In  the  first  two  years,  the  edge  can  be  easily  felt 
about  2  cm.  below  the  costal  border  in  the  mammary  line.  Later, 
the  distance  becomes  somewhat  less,  but  until  the  later  years  of 
childhood,  the  edge  of  the  liver  can  still  be  felt  below  the  costal 
border.     Only  in  late  childhood  does  the  liver  no  longer  descend 


16 


The  Normal  Child 


below  the  edge  of  the  ribs  in  the  mammary  line,  but  even  at  this 
period,  owing  to  the  laxness  of  the  abdominal  walls,  the  edge  of  the 
liver  can  sometimes  be  felt  by  pushing  the  palpating  fingers  up  under 
the  ribs. 

Fig.  6 


Normal  development  at  twelve  years 

THE  SPLEEN. — The  spleen  presents  no  differences  in  size  or 
position  characteristic  of  childhood.  It  may  sometimes  be  felt,  by 
pushing  the  fingers  up  under  the  costal  border,  but  normally  is  never 
felt  below  the  costal  border, 

THE  LIMBS. — The  limbs  in  infancy  are  short  in  proportion  to 
the  trunk.  Holt  has  found,  from  one  hundred  and  fifty  observa- 
tions, that  the  length  of  the  lower  extremities  at  birth  (measuring 
from  the  anterior  superior  spine  of  the  ileum  to  the  sole  of  the  foot), 
is  forty- three  per  cent,  of  the  length  of  the  body;  at  five  years  it  is 
fifty-four  per  cent.,  and  at  sixteen  years,  sixty  per  cent.  The  pad 
of  fat,  which  gives  the  infant  the  appearance  of  flat-foot,  is,  accord- 
ing to  Dane,  designed  to  support  the  arch  of  the  foot  until  the  mus- 


Normal  Development  17 

cles  are  stronger.     It  is  slowly  absorbed,  and  by  the  fourth  or  fifth 
year,  the  foot  presents  the  same  appearance  as  in  the  adult. 

MUSCULAR  DEVELOPMENT.— At  birth,  the  strongest  mus- 
cular development  is  seen  in  the  hands  and  forearms.  Voluntary 
attempts  to  grasp  objects  are  seen  at  about  the  beginning  of  the 
fourth  month.  The  infant  should  be  able  to  hold  up  its  head  with 
only  the  back  supported,  by  the  fourth  month,  though  sometimes 
this  is  seen  as  early  as  the  end  of  the  second  month.  It  begins  to 
sit  alone  at  between  the  seventh  and  ninth  months,  and  creeps  at 
ten  months.  Soon  after  this  are  seen  the  first  attempts  to  stand, 
the  infant  trying  to  pull  himself  up  with  the  aid  of  his  nurse's  skirts, 
or  of  pieces  of  furniture.  It  can  usually  stand  at  twelve  months, 
and  soon  after,  makes  its  first  attempts  at  walking.  There  are  wide 
variations  in  the  age  at  which  the  normal  infant  learns  to  walk. 
Some  infants  learn  to  walk  at  twelve  or  thirteen  months,  and  others, 
apparently  normal,  do  not  walk  until  they  are  seventeen  or  eighteen 
months  old.     The  average  age  is  fifteen  months. 

MENTAL  DEVELOPMENT  AND  THE  SENSES.— The  eyes 
of  the  infant  at  birth  are  sensitive  to  light;  by  the  end  of  the  second 
or  third  week  they  will  follow  a  bright  light.  The  infant  seldom 
smiles  before  the  fifth  or  sixth  week;  he  does  not  recognize  objects 
before  the  sixth  or  eighth  week.  The  muscles  of  the  eye  in  early 
infancy  act  irregularly,  and  coordinate  action  is  not  seen  until  the 
third  or  fourth  month,  and  sometimes  incoordination  is  seen  for  a 
considerably  longer  period. 

The  hearing  is  undeveloped  at  birth,  and  for  the  first  few  days 
infants  are  deaf.  The  movements  of  respiration  and  deglutition 
cause  the  eustachian  tubes  to  be  cleared  of  mucus,  air  enters  the 
middle  ear,  and  the  hearing  gradually  improves  After  the  first 
month  it  is  very  acute,  the  infant  being  easily  disturbed  by  noises. 
Usually  by  the  fifth  month  the  infant  will  show  distinct  signs  of 
distinguishing  and  interpreting  particular  sounds,  and  of  recognizing 
individual  voices.  At  this  time  it  may  very  easily  be  frightened  by 
loud  or  unusual  noises. 

The  sense  of  touch,  while  present,  is  not  very  acute  at  birth,  except 
in  the  lips  and  tongue.  It  develops  rapidly,  and  by  the  end  of  the 
third  month,  is  fairly  acute  all  over  the  body.  Sensibility  to  pain, 
while  present  in  infancy,  is  dull  compared  with  later  childhood. 
The  localization  of  sensory  impressions  is  very  imperfect  throughout 
the  first  years  of  life. 

Taste  is  said  to  be  developed  at  birth,  but  I  believe  its  develop- 
ment is  poor  during  the  earlier  weeks.  It  is  usually  said  to  be  acute 
throughout  the  greater  part  of  infancy  and  childhood,  this  statement 
being  based  on  the  fact  that  the  child  easily  detects  changes  in  its 


18  The  Normal  Child 

food.  I  believe  that  taste  is  only  acutely  developed  in  the  case  of 
the  primary  tastes  of  sweet,  sour,  bitter,  and  salt.  The  foods  which 
it  receives  during  the  first  year  show  variations  only  in  these  primary 
tastes.  I  be  ieve  that  the  infant  does  not  perceive  flavors,  and 
that  this  inability  to  detect  variations  other  than  the  simplest  in  the 
>aste  of  its  food  persists  through  some  of  the  earlier  years  of  child- 
hood. The  infant  is  very  sensitive  to  the  feeling  of  various  foods  in 
the  mouth,  and  it  is  this  sensibility  to  the  sensation  of  the  food  which 
is  mistaken  for  a  highly  developed  sense  of  taste.  Young  children 
do  not  usually  object  to  the  taste  of  castor  oil,  unless  it  has  been 
suggested  to  them  that  castor  oil  has  a  bad  taste. 

The  sense  of  smell  has  not  been  conclusively  tested  in  infancy. 
This  sense  is  probably  present,  but  develops  much  more  slowly  than 
the  other  senses.  Fine  distinctions  in  odors  are  not  detected  until 
the  late  years  of  childhood. 

SPEECH. ^During  the  first  year  of  its  life  the  average  infant 
uses  its  voice  merely  in  crying  to  express  its  discomforts  or  desires. 
At  about  the  end  of  the  first  year  it  usually  begins  to  enunciate 
single  words,  and  in  the  middle,  or  toward  the  end  of  the  second 
year  it  learns  to  form  short  sentences.  From  this  time  on,  the  faculty 
of  talking  progresses  rapidly,  but  children  do  not  usually  learn  to 
talk  connectedly  till  the  third  or  fourth  year.  There  is  great  varia- 
tion in  the  time  when  the  faculty  of  speech  is  acquired.  Many 
children,  who  understand  perfectly,  make  all  their  wants  known  by 
signs,  and  who  show  no  other  signs  of  delayed  mental  development, 
show  a  delay  of  from  one  to  two  years  in  every  phase  of  the  develop- 
ment of  the  speech  faculty.     Girls  learn  to  talk  earlier  than  boys. 

DEVELOPMENT  OF  OTHER  FUNCTIONS.— The  function  of 
the  lachrymal  glands  does  not  usually  develop  till  the  baby  is  three 
or  four  months  old.  The  time  of  its  development  is  variable.  Babies 
have  been  observed  to  cry  tears  as  early  as  the  first  month. 

The  development  of  the  function  of  the  sweat  glands  is  also  very 
variable.  It  is  occasionally  seen  developed  at  birth.  Usually,  how- 
ever, perspiration  is  not  seen  till  the  third  to  the  fifth  week. 

The  salivary  secretion  is  developed  rather  slowly  in  early  infancy. 
There  is  not  much  saliva  seen  in  the  infant's  mouth  in  the  first  three 
or  four  months  of  life. 

THE  URINE.— The  function  of  the  kidney  begins  quite  early  in 
fetal  Hfe,  and  the  bladder  has  been  found  to  be  full  of  urine  at 
birth.  The  urine  is  small  in  amount  at  birth,  and  during  the  first 
twenty-four  hours  it  is  not  uncommon  to  find  little  or  none  passed. 
The  urine  which  is  first  passed  is  usually  dark,  cloudy,  and  acid, 
and   contains  epitheUal   cells   and   urates   and   occasionally  hyaline 


Normal  Development  19 

casts;  later  it  becomes  clear,  pale,  straw-yellow,  and  usually  of  slightly 
acid  reaction.  Its  specific  gra\'ity  (i.oio  at  birth)  falls  in  two  or  three 
days  to  1.003,  t»y  about  the  fifteenth  day  is  found  to  be  1.006,  and 
rises  from  this  time  steadily  till  puberty.  By  the  end  of  the  first 
week  and  throughout  childhood  the  amount  of  urine  passed  in  twenty- 
four  hours  is  relatively  greater  than  in  adult  life.  This  in  early  in- 
fancy may  be  due  to  the  prepDnderance  of  liquid  food,  but  is  in 
part  the  result  o"  the  infant's  more  active  metabolism,  for  the  urea 
is  also  found  to  be  proportionately  increased.  According  to  Foster, 
the  presence  of  uric  and  oxalic  acid  in  unusual  quantities  is  a  frequent 
characteristic  of  the  urine  of  children.  It  is  also  stated  that  the 
phosphates  are  deficient,  being  retained  in  the  body  for  the  purpose 
of  building  up  the  osseous  system.  The  chlorides,  sulphates  and 
urinary  pigments  are  less  abundant  than  in  the  adult.  The  propor- 
tion of  salts  increases  as  soon  as  a  mixed  diet  is  given  and  closely 
approaches  the  normal  proportion  for  adults.  Indican  is  normally 
absent  in  breast  fed-infants;  in  others  it  is  usually  absent  unless 
there  is  a  disturbance  of  digestion.  The  uric  acid  infarction,  which 
has  been  referred  to,  and  evidences  of  which  may  last  for  two  or 
three  weeks,  consists  of  urate  of  ammonium  (hedgehog  crystals), 
amorphous  urates  mixed  with  uric  acid  crystals,  and  some  epithelial 
cells.  The  variations  in  the  amount  of  urine  which  has  been  com- 
puted to  be  passed  during  the  early  days  of  infancy  and  childhood 
are  very  great,  as  the  amount  in  all  probabihty  depends  very  largely 
on  the  quantity  of  liquid  ingested,  and  also  upon  the  activity  of  the 
skin  and  bowels. 

The  difficulties  in  accurately  measuring  the  amount  of  urine  ex- 
creted by  very  young  infants  are  such  that  few  positive  statements 
can  be  made  as  to  the  quantity.  It  is  sufficient  to  say  that  it  is  about 
ninety  cubic  centimeters  (three  ounces)  a  day  for  the  first  few  days, 
and  then  rises  in  amount  very  rapidly. 

Reitz  and  Cruse  state  that  during  the  first  few  days  of  life  the 
urine  contains  more  or  less  albumin,  and  that  this  disappears  at 
about  the  seventh  or  eighth  day,  though  sometimes,  according  to 
Carpenter's  work,  it  may  be  detected  for  several  weeks.  Lesne  and 
Merklen  found  the  freezing  point  at  birth  0°  C,  at  one  month  —0.13° 
to  —0.35°  C,  at  two  months  —0.21°  to  —0.78°  C.  Sugar  is  occa- 
sionally found  in  the  urine  of  healthy  infants  during  the  first  two 
months. 

The  urine  sediment  of  the  young  infant  shows  on  microscopical 
examination,  mucus,  many  epithelial  cells,  crystals  of  uric  acid, 
urates,  and  calcium  oxalate;  also  amorphous  urates,  occasionally  a 
few  hyahne  casts,  and  rarely  a  granular  cast.  The  urine  of  later 
infancy  and  childhood  has  no  microscopical  peculiarities. 


20  The  Normal  Child 

INTESTINAL  DISCHARGES.— The  contents  of  the  intestine 
continue  to  be  mixed  with  meconium  for  three  or  four  days  or  a 
week,  the  longer  time  being  when  the  infant  is  weak  and  does  not 
nurse  well.  After  this  time  the  infantile  discharges,  which  have  a 
characteristic  appearance  as  distinguished  from  those  of  the  older 
child,  appear.  When  the  nutrient  is  human  milk,  the  discharges 
are  of  a  golden-yellow  color,  smooth,  unformed,  of  medium  consis- 
tency, showing  a  large  proportion  of  water,  and  sometimes  changing 
to  a  greenish  yellow  on  exposure  to  the  air.  If  the  baby  is  arti- 
ficially fed,  the  movements  are  normally  of  a  lighter  yellow  color, 
and  of  slightly  firmer  consistency.  They  as  a  rule  contain  unde- 
composed  bile-pigment  and  bile-salts,  while  the  older  child's  and  the 
adult's  discharges  do  not  contain  the  bile  undecomposed.  The  amount 
of  fecal  discharge  in  the  first  day  of  life  is  about  forty-five  grammes 
(one  and  one-half  ounces),  and  increases  in  the  following  days  to  fifty 
grammes  (one  and  two- thirds  ounces).  It  consists  of  mucus,  fat, 
epithelial  remains,  and  a  slight  amount  of  albuminoid  material.  In 
early  infancy  there  are  from  two  to  four  discharges  daily.  As  the 
child  grows  older  there  are  two  and  finally  one  in  the  twenty-four 
hours.  They  do  not  lose  their  yellow  color  until  amylaceous  or  al- 
buminous food  is  given,  when  the  different  shades  of  brown  begin  to 
appear.  They  are  not  fully  formed  until  something  besides  milk  is 
swallowed.  Starting  at  birth,  with  the  sterile  meconium,  infection 
by  the  mouth  and  rectum  quickly  occurs,  and  in  a  short  time  many 
forms  of  bacteria  may  be  found  in  the  discharges. 

TEMPERATURE.— The  rectal  temperature  of  the  newly-born 
infant  varies  to  a  certain  extent,  lying  between  99°  F.,  and  100.5°  F. 
Very  soon  after  birth,  as  would  be  expected  from  the  tax  which  is 
made  on  the  infant  by  its  surroundings,  the  temperature  shows  a 
slight  fall,  varying  between  98°  F.,  and  99.5°  F.  By  the  end  of  the 
first  week,  the  normal  temperature  of  the  infant  is  regained,  and 
during  the  first  year,  the  temperature  ranges  from  99°  F.  to  100.5°  ^• 
In  the  second  year,  and  during  early  childhood,  the  temperature  is 
98.5°  F.,  to  100°  F.,  and  in  later  childhood,  the  normal  temperature 
is  that  of  the  adult. 

PULSE. — Immediately  after  birth,  the  pulse  is  often  quite  irreg- 
ular, but  soon  becomes  perfectly  regular  in  rhythm.  The  small 
volume  and  force  of  the  infant's  pulse  is  proportionate  to  the  small 
size  of  a  baby  as  compared  with  an  adult.  The  rate  of  the  pulse 
presents  the  most  extreme  variations  in  early  life,  especially  during 
the  first  year.  It  is  much  affected  by  nervous  influences.  The 
table  shows  the  average  pulse  rate  at  the  various  ages  for  males; 
in  girls  the  rate  is  apt  to  be  somewhat  higher. 


Normal  Development  21 

Table  5 
Pulse-Rate  for  Males 

AGE  PULSE-BEATS  PER  MINUTE 

Early  weeks 1 20  to  140 

Until  2d  year no 

2  to  3  years 100 

5  to  8  years 90 

After  the  eighth  year  the  pulse  gradually  acquires  the  adult  rate. 

RESPIRATION. — The  rhythm  of  respiration  in  very  young  in- 
fants is  so  easily  affected,  varying  with  every  disturbance,  and  even 
with  changes  of  temperature,  that  a  regular  rate  of  respiration  is 
only  seen  when  the  infant  is  asleep.  At  all  other  times  the  respira- 
tion is  very  irregular  in  rhythm,  even  when  the  child  is  quiet.  It 
may  be  quite  superficial  for  a  few  moments,  and  then  quite  deep. 
There  are  frequent  pauses;  at  times  one  lung  appears  to  be  used 
exclusively  for  a  brief  period.  A  regular  rhythm  is  not  fully  estab- 
lished till  the  child  is  two  years  old.  The  character  of  the  respira- 
tion in  early  infancy  is  wholly  diaphragmatic,  and  remains  mainly 
diaphragmatic  until  the  sixth  or  seventh  year.  From  this  time  on 
the  costal  element  gradually  become  ,  prominent. 

The  rate  of  respiration  is  also  extremely  variable.  At  birth  it  is 
usually  from  35  to  45  per  minute  when  the  child  is  quiet.  Until 
the  third  year  it  varies  from  15  to  40  per  minute,  and  from  three 
to  five  years,  the  rate  is  20  to  25  per  minute. 

Fig.  7 


QUICK  PAUSE  SLOW  QUICK 

Respiration  at  birth  for  one-fourth  minute.     Awake,  but  quiet 

HEIGHT. — The  average  height  of  the  male  infant  at  term  is, 
according  to  a  large  number  of  measurements  about  49.5  cm.  (igf 
inches).  Insufficient  nourishment  and  improper  food,  especially  as 
represented  in  rhachitic  children,  seem  to  retard  the  growth,  while 
on  the  contrary,  the  various  fevers  seem  to  increase  the  activity 
of  growth  in  length,  while  decreasing  the  total  weight.  In  the  first 
three  or  four  months  the  growth  is  proportionately  rapid  to  that  in 
the  latter  part  of  the  first  year.  In  like  manner  the  activity  is  greater 
in  the  first  month  than  in  the  second,  and  in  the  second  than  in  the 
third,  becoming  still  less  in  the  fourth,  fifth  and  sixth  months. 

Table  6 
The  average  increase  for  the  first  month  is  about  4.5  cm.  (if  in.) 
"  "  "         "      "    second  month  is  about  3.0  cm.  (i|  in.) 

"  "  "         "      "    third  to  the  fifteenth  month  is  about  i  to  1.5  cm.  {\  to  J  in.) 

"  "  «         «      «    flrst  year  is  about  20  cm.  (8  in.) 


22  The  Normal  Child 

Table  6 — Continued 
The  average  increase  for  the  second  year  is  about  9  cm.  (3I  in.) 
"  "  "         "      "    third  year  is  about  7.4  cm.  (3  in.) 

"  "  "         "      "    fourth  and  fifth  years  is  about  6.4  cm.  (af  in.) 

"  "  "         "      "    fifth  to  sixth  year  is  about  6  cm.  (af  in.) 

The  height  is  about  doubled  in  the  first  six  years,  and  at  fourteen 
years  the  final  height  has  usually  been  attained  to  within  about  one- 
twelfth.  The  height  at  different  ages  in  comparison  with  the  weight 
will  be  shown  in  table.  8. 

WEIGHT. — The  normal  infant  manifests  its  growth  and  develop- 
ment most  clearly  by  increasing  in  weight.  All  other  signs  of  dis- 
turbance of  normal  development  are  not  at  once  apparent,  but  mani- 
fest themselves  slowly.  Increase  in  weight,  on  the  other  hand,  is 
a  more  or  less  continuous  process  of  development,  any  disturbance 
of  which  manifests  itself  at  once.  Moreover,  this  growth  in  weight 
is,  of  all  the  processes  of  development,  the  one  most  easily  disturbed 
by  all  kinds  of  adverse  influences,  and  therefore  is  the  most  valuable 
and  delicate  index  of  health  which  we  have.  Of  all  the  data  which 
guide  the  physician  in  the  care  of  infants,  the  records  of  the  weights 
taken  from  time  to  time  are  the  most  important.  The  physician  in 
the  wards  of  an  infants'  hospital  looks  first  at  the  weight  curves 
depicted  on  the  charts.  In  older  children,  the  weight  records  are 
less  important  than  in  the  first  two  years  of  life,  but  nevertheless 
afford  valuable  data  throughout  the  period  of  growth. 

The  weight  of  the  newborn  infant  is  very  variable,  and  can  only 
be  expressed  by  an  average.  It  must  be  remembered  that  wherever 
any  figure  representing  the  normal  is  based  on  the  method  of  averag- 
ing normal  variations,  a  deviation  from  the  normal  figure  in  an  indi- 
vidual case  does  not  of  itself  constitute  an  abnormality.  The  limits 
of  weight  variation  of  full  term  infants  at  birth  are  not  definitely 
known,  but  a  birth  weight  of  six  pounds  or  over  should  be  considered 
within  normal  limits;  a  birth  weight  of  under  six  pounds  is  strongly 
suggestive  of  impaired  vitality.  The  average  birth  weight  for  males 
is  yf  pounds;  for  females  it  is  7I  pounds. 

During  the  first  three  or  four  days  of  life  there  is  a  loss  of  weight, 
which  is  usually  designated  as  physiological.  This  initial  loss  of 
weight  often  amounts  to  9  or  10  ounces.  Not  all  of  it  is  strictly 
physiological,  but  only  that  part  of  it,  amounting  to  4  or  5  ounces, 
which  can  be  accounted  for  by  the  passage  of  meconium.  The 
additional  loss  is  nutritional  in  origin,  and  is  due  to  an  excess  of 
tissue  waste  over  nutriment.  The  secretion  of  the  breasts  is  estab- 
lished rather  slowly,  and  during  the  first  days  of  life  the  infant 
obtains  comparatively  Httle  food.  The  nutrition  is  probably  further 
affected  by  the  tax  on  the  infant's  vitality  caused  by  the  sudden 
change  in  its  surroundings. 


Normal  Development  23 

By  the  third  or  fourth  day,  when  the  milk  secretion  is  estabhshed, 
the  normal  infant  begins  to  gain  continuously  in  weight.  Failure 
to  gain  at  this  time  is  seen  only  when  the  milk  secretion  is  estab- 
lished unusually  slowly,  when  colostrum  milk  persists  unduly,  or 
when  some  other  cause  is  present  which  actually  produces  a  condition 
of  disease.  The  initial  weight  is  usually  regained  during  the  second 
week.  If  it  is  not  regained  by  the  third  week,  we  must  look  for  some 
cause  disturbing  normal  development.  In  artificially  fed  infants,  the 
initial  weight  is  often  not  so  rapidly  regained  as  in  the  breast-fed. 

During  the  first  year  of  life,  increase  in  weight  is  normally  con- 
tinuous, and  comparative  y  rapid.  The  gain  is  most  rapid  during 
the  first  three  months;  in  this  period  the  average  daily  gain  is  almost 
two-thirds  of  an  ounce.  The  gain  is  not,  however,  steady  from  day 
to  day,  a  large  gain  on  one  day  being  often  counterbalanced  by  a 
failure  to  gain  on  the  next  day.  The  rate  of  gain  can  best  be  judged 
by  comparing  the  records  from  week  to  week.  In  the  second  three 
months  the  gain  in  weight  is  not  quite  so  rapid.  In  the  third  quar- 
ter, the  rate  of  gain  is  the  slowest  of  any  of  the  periods  of  the  first 
year,  and  becomes  shghtly  more  rapid  in  the  fourth  quarter.  The 
following  table  shows  the  average  rate  of  gain  in  normal  infants, 
in  the  four  quarters  of  the  first  year: 

Table  7 

total  gain  weekly  gain 

grammes       pounds  grammes      ounces 

First  three  months 2400  5  180  6.2 

Second  three  months 1920  4  148  5 

Third  three  months 1200  2I  92  3.1 

Fourth  three  months 1320  2f  102  3.5 

The  figures  for  the  weekly  gain  represent  an  average,  and  are 
rather  larger  than  are  often  seen  in  babies  who  in  every  respect 
develop  normally.  One  should  not  be  worried  as  to  the  development 
of  any  baby  whose  weekly  gain  in  weight  was  4  ounces  for  the  first 
three  months,  3  ounces  for  the  second  three  months,  and  2  ounces 
for  the  last  six  months  of  the  first  year. 

It  is  customary  to  picture  the  weight  development  of  an  infant 
in  the  form  of  a  weight  curve,  such  as  that  shown  in  the  chart. 

Such  a  chart  represents  the  average  rate  of  gain  of  a  number 
of  healthy  babies.  It  must  not  be  taken  too  Hterally  in  comparison 
with  the  weight  curve  of  an  individual  baby.  The  rate  of  gain  in 
individual  babies  is  usually  not  so  steadily  continuous  as  in  the 
ideal  infant's  weight  chart.  In  many  normal  babies  there  are  periods 
when  the  rate  of  gain  is  much  less  than  the  average,  or  in  which 
there  is  even,  for  a  time,  no  gain  in  weight.  Such  a  period  of  slight 
gain  or  of  stationary  weight  is  particularly  likely  to  be  seen  in  the 
third  quarter  of  the  first  year.     In  any  child  there  are  apt  to  be 


24 


The  Normal  Child 


Chart  i 


Name, 


Date  of  Birth,. 


Months.  1 

Weeks.    13 


10  11  12   13   14  15     16   17   18    19   20    21    22   23    24 

I  I  I      I      I       I       I      I       I      I       I     -I      I      I 

9   11  13   15  17i  19   21   23   2.'>  27   29   31  33  35  37  39  41   13  45  47  49  51      5fi   CO  64  68   72  76  80  8i   88  92  96  100104 


Weeks.    1    3    6    7    9    H  X3  15  IT  19  U  83  85,  27  29  31  33  35  37  39  41  43  45  47  49  5J,      §8  fig  64 '^9  78  76  80  64  88  98  96  10010* 

0E8IQNE0BY  J.P,  CROZER  GRIFFITH,  M.O. 

Infant's  Weight  Chart 

periods  when  new  processes  of  growth,  such  as  dentition,  or  new  func- 
tions, such  as  noticing,  walking,  or  talking,  are  being  rapidly  devel- 
oped. At  such  times  the  gain  in  weight  is  less  pronounced.  The 
weight  chart  is  useful  as  a  general  guide  for  comparison  in  estimating 


Normal  Development 


25 


the  development  of  the  baby,  but  it  represents  an  ideal  condition, 
which  is  often  not  attained. 

A  further  extension  of  such  a  method  of  comparison  provides 
a  weight  index  for  estimating  the  weight  development  of  any  infant. 
This  weight  index  is  expressed  by  dividing  the  weight  of  the  infant 
by  the  weight  of  the  average  healthy  infant  of  the  same  age.  If 
the  quotient  is  multiplied  by  loo,  the  result  expresses  in  per  cent, 
the  weight  development  of  the  baby.  This  is  useful  as  a  general 
guide,  but  again,  must  not  be  taken  too  literally  as  a  criterion  of 
normal  development,  on  account  of  the  factor  of  individual  variation. 
It  must  also  be  remembered  that  babies  who  are  above  or  below 
the  average  at  birth,  are  apt  to  keep  the  same  relation  to  the  average 
throughout  much  of  the  first  year.     This  is  shown  in  the  chart. 


Inf aat  C  5 


Chart 


The  middle  line  "B"  represents  the  weight  curve  of  the  average 
healthy  infant.  This  curve  is  taken  as  the  constant  by  which  to 
estimate  the  weight  index  of  any  infant.  The  perpendicular  lines 
represent  the  number  of  pounds  the  child  gains  in  the  four  quarters 
of  the  first  year.  The  weight  index  of  such  an  infant  is  i.o,  the 
weight  development  loo  per  cent. 

The  upper  curve  ''A"  represents  the  theoretical  curve  of  an  in- 
fant weighing  9  pounds  at  birth,  with  a  resulting  weight  index  of 
1.2.  If  such  an  infant  were  to  maintain  throughout  the  first  year 
the  advantage  in  weight  development  with  which  it  starts  out  in 
life,  its  quarterly  gains  in  pounds  would  be  as  are  indicated  in  the 
perpendicular  lines.  These  will  be  seen  to  vary  considerably  from 
those  of  the  average  healthy  infant  represented  in  curve  "B." 

In  a  similar  manner  curve  "C"  represents  the  theoretical  weight 
curve  of  a  5^  pound-baby,  with  a  weight  index  of  0.7,  and  the  per- 
pendicular lines  show  the  quarterly  gains  in  pounds,  which  would 
be  necessary  to  maintain  throughout  the  first  year  the  weight  devel- 
opment with  which  it  starts  in  life.  These  are  seen  to  be  considerably 
less  than  those  of  the  average  healthy  infant. 


26  The  Normal  Child 

Now,  for  example,  if  the  infant  C  and  infant  A  each  gain  from 
the  sixth  to  the  ninth  month  5  pounds,  instead  of  the  theoretical 
gains  expressed  in  the  perpendicular  lines,  one  will  find  by  working 
out  the  above  formula,  that  the  weight  index  of  infant  C  has  been 
raised  to  0.85,  a  gain  of  15  per  cent,  in  weight  development;  that 
the  weight  index  of  infant  A  has  been  raised  to  1.30,  a  gain  of  10  per 
cent,  in  weight  development.  In  other  words,  although  each  infant 
has  gained  the  same  number  of  pounds  in  three  months,  the  smaller 
infant  C  has  gained  proportionately  5  per  cent,  more  in  weight  de- 
velopment than  the  larger  infant  A. 

It  is  not  to  be  supposed  that  every  healthy  infant  weighing  above 
normal  at  birth  and  having  a  weight  development  above  100  will 
maintain  throughout  the  first  year  the  same  percentage  of  develop- 
ment with  which  it  starts  out  in  life;  some  will  and  others  will  not. 
There  is  in  the  majority  of  cases  a  tendency  for  the  line  of  growth 
of  these  large  infants  to  dip  downward  and  gradually  to  approach 
the  weight  curve  of  the  average  child. 

On  the  other  hand  there  is  a  great  tendency  for  the  undersized 
infants,  if  properly  fed,  to  grow,  relatively  to  their  initial  weight 
development,  faster  than  the  average  child,  and  their  line  of  growth 
tends  upward  to  meet  that  of  the  average  infant.  In  judging  the 
effects  of  feeding  upon  two  such  theoretical  cases  as  "A"  and  "B" 
in  the  above  example,  it  is  obviously  unfair  to  take  the  number  of 
pounds  gained  in  each  quarter  by  each  infant  as  the  sole  basis  of 
comparison.  A  more  exact  and  scientific  method  is  to  indicate  their 
rate  of  growth  in  percentages  of  development.  We  may  thus  express 
with  clearness  and  in  easily  understood  terms  their  progress  either 
in  reference  to  each  other  or  to  the  average  healthy  child. 

The  weight  index,  then,  while  not  embodying  any  fixed  law  of 
growth  may  be  used  to  express  in  definite  percentages  the  variations 
in  weight  development  of  an  infant  which  may  occur  as  a  result  of 
natural  growth  or  disease. 

During  the  second  year  the  gain  in  weight  is  much  less  constant 
and  steady  than  in  the  first  year.  There  is,  of  course,  stationary 
weight,  or  loss  of  weight,  with  every  illness.  Also,  even  when  there 
is  no  illness,  and  when  the  child  is  developing  normally  in  every  other 
respect,  there  are  periods  when  the  gain  is  very  shght,  or  when  the 
weight  is  stationary.  Such  periods  are  particularly  seen  in  the 
summer  months;  many  otherwise  normal  children,  do  not  gain  weight 
during  an  entire  summer.  The  rate  of  growth  is  apt  to  be  fastest  in 
the  autumn  and  early  winter. 

In  the  earlier  years  of  childhood,  the  same  conditions  of  weight  devel- 
opment prevail  as  in  the  second  year.  In  the  later  years  of  childhood 
the  weight  increase  is  slower,  but  rather  more  steadily  constant. 


Normal  Development 


27 


The  figures  for  the  average  weights  and  heights  of  normal  chil- 
dren throughout  infancy  and  childhood  are  shown  in  the  table. 

They  afford  a  ready  basis  of  comparison  in  estimating  weight  de- 
velopment, showing  the  relation  of  the  individual  child  at  all  times 
to  the  average  normal. 

Table  8 

Average  Heights  and  Weights  from  Birth  to  Five  Years,  and  of  Boston  School  Boys  and 
Girls,  Irrespective  of  Nationality,  from  Five  to  Fourteen  Years 


Boys 

AGE 

Girls 

HEIGHT 

WEIGHT 

HEIGHT 

WEIGHT 

Centimetres 

Inches 

Kilogrammes 

Pounds 

Centimetres 

Inches 

Kilogrammes 

Pounds 

49-37 

1975 

3-25 

7-15 

Birth 

48.12 

19-25 

3-15 

6.93 

6i 

«7 

24 

75 

6 

5° 

14 

30 

5  months 

5912 

23 

25 

6.30 

13.86 

73 

82 

29 

53 

9 

54 

20 

98 

I  year 

74-17 

29 

07 

9.00 

19.80 

84 

55 

33 

82 

13 

80 

30 

36 

2  years 

82.35 

32 

94 

13-31 

29.  28 

92 

&5 

37 

06 

IS 

90 

34 

98 

3  years 

90.77 

3b 

31 

15-07 

33-15 

98 

27 

39 

31 

17 

27 

37 

99 

4  years 

97.00 

38 

80 

16.53 

36.36 

103 

92 

41 

57 

18 

04 

41 

00 

5  years 

103.22 

41 

29 

17.99 

39-57 

109 

37 

43 

75 

20 

49 

45 

07 

6  years 

108.37 

43 

35 

19.63 

43-18 

114 

35 

45 

74 

22 

20 

48 

97 

7  years 

113.80 

45 

52 

21.50 

47-30 

119 

40 

47 

76 

24 

46 

53 

81 

8  years 

118.95 

47 

58 

23-44 

51-56 

124 

22 

49 

09 

2b 

«7 

59 

00 

9  years 

123.42 

4Q 

37 

25-91 

57-00 

129 

20 

51 

68 

29 

62 

65 

16 

10  vears 

128.35 

51 

34 

28.29 

62.23 

133 

32 

53 

33 

31 

84 

70 

04 

II  years 

133-55 

53 

42 

31-23 

68.70 

137 

77 

55 

II 

34 

89 

76 

75 

12  years 

139.70 

55 

88 

35-53 

78.16 

143 

02 

57 

21 

3« 

49 

84 

67 

13  years 

145-40 

58 

16 

40.21 

88.46 

149 . 70 

59.88 

42.9s 

94 

49 

14  years 

149-85 

59 

94 

44.65 

98-23 

In  remembering  the  course  of  normal  weight  development,  useful 
figures  are  the  following :  An  average  child  doubles  its  birth  weight 
at  five  months,  and  trebles  it  at  fifteen  months.  At  five  years  its 
weight  is  double  that  seen  at  the  end  of  the  first  year,  and  its  weight 
at  five  years  is  doubled  at  twelve  years. 


DEVELOPMENT  OF  INTERNAL  STRUCTURE 

In  order  that  the  student  of  pediatrics  may  recognize  certain  path- 
ologic conditions  found  on  post-mortem  examination,  it  is  essential 
that  he  be  familiar  with  the  features  of  internal  structure  which  are 
peculiar  to  early  life.  The  development  of  those  internal  parts  of 
the  body  which  at  birth  show  anatomic  peculiarities  will  be  traced. 

The  development  of  function,  such  as  that  of  the  digestive  and 
urinary  systems,  is  also  of  great  importance  to  the  student  of  pedia- 
trics. This  phase  of  development  is,  however,  so  closely  connected 
with  the  various  gastro-enteric  and  renal  diseases,  that  its  discus- 
sion will  be  postponed  until  these  diseases  are  considered.  Anatomic 
development  only  will  be  considered  at  present. 


28  The  Normal  Child 

THE  BRAIN. — The  brain  grows  rapidly  during  the  first  seven 
years  of  Kfe;  after  this  age  it  increases  very  slowly  in  weight.  The 
convolutions  are  not  fully  developed  at  birth,  and  are  gradually  per- 
fected as  the  child  grows  older.  One  important  anatomical  condi- 
tion in  the  brain  of  young  subjects  is  that  the  dura  mater  is  much 
more  adherent  to  the  skull  than  in  later  life.  The  subarachnoid 
space  also,  contains  a  larger  amount  of  fluid. 

THE  EAR. — At  birth  there  exists  in  the  roof  of  the  middle  ear 
a  distinct  cleft  between  those  portions  of  the  tegmen  tympani  which 
are  formed  by  the  petrous  and  squamous  bones.  Through  this  cleft 
extends  a  small  process  of  the  dura.  This  cleft  closes  at  about  the 
beginning  of  the  fifth  month,  becoming  the  petrosquamosal  suture. 
It  does  not  in  early  life,  appear  to  play  any  role  in  permitting  puru- 
lent processes  to  extend  from  the  ear  into  the  cranial  cavity. 

The  cavity  of  the  antrum  is  present  at  birth,  but  the  mastoid 
process  is  very  slightly  developed,  there  being  no  mastoid  cells.  At 
the  end  of  the  first  year,  the  mastoid  begins  to  contain  a  few  pneu- 
matic cells.  It  becomes  fully  developed,  resembling  the  adult  mas- 
toid, at  three  years. 

The  osseous  meatus  is  not  developed  until  about  the  fourth  year. 
In  introducing  the  ear  speculum  at  a  period  previous  to  the  fourth 
year,  the  ear  should  be  drawn  backward  and  downward,  instead  of 
backward  and  upward. 

THE  NASOPHARYNX.— The  nasal  cavity  begins  to  increase  in 
height  directly  after  birth,  and  its  growth  is  rapid  until  the  begin- 
ning of  dentition.  After  the  completion  of  the  first  dentition,  the 
growth  is  again  rapid  until  the  seventh  year,  during  which  period 
takes  place  the  chief  increase  in  breadth,  and  the  growth  of  the 
olfactory  portion.  At  the  end  of  the  seventh  year,  the  cavity  ap- 
proaches the  adult  shape,  although  it  still  seems  broad  in  propor- 
tion, and  of  course  has  not  attained  the  adult  size. 

The  change  in  the  shape  of  the  pharynx  is  very  rapid  during  in- 
fancy.    It  attains  the  adult  shape  at  about  the  age  of  three  years. 

There  is  little  change  in  the  position  of  the  eustachian  tubes  up 
to  the  ninth  month.  After  this,  the  openings  are  higher  than  the 
floor  of  the  nasal  cavity. 

The  pharyngeal  tonsil  increases  rapidly,  after  birth,  and  by  the 
end  of  the  third  year  has  a  length  of  eighteen  millimeters. 

THYMUS  GLAND.— The  thymus  is  most  developed  in  the  first 
two  years  of  life,  but  it  persists  longer  than  was  formerly  taught. 
During  its  greatest  development  it  is  found  in  the  neck  as  well  as 
in  the  thorax,  extending  perhaps  2  cm.  (f  inch)  above  the  sternum. 
The  thymus  extends  down  the  anterior  mediastinum,  lying  on  the 
pericardium  in  two  long  lobes  on  either  side  of  the  median  line.     The 


Normal  Development  29 

extent  of  these  lobes  is  very  variable,  and  the  two  are  not  usually 
symmetrical.  I  have  seen  them,  even  in  an  infant,  so  developed  that 
the  longer  nearly  reached  the  lower  end  of  the  sternum;  but  it  is 
very  uncommon  for  it  to  reach  the  diaphragm.  These  prolongations 
become  thinner  as  they  descend.  The  thymus  is  a  thick  mass  behind 
the  first  piece  of  the  sternum,  where  it  rests  on  the  top  of  the  heart 
against  the  great  vessels  concealing  the  innominate  veins,  more  or 
less  of  the  superior  vena  cava  and  the  arch  of  the  aorta,  and  extend- 
ing back  to  the  trachea.  Lower  down  it  extends  on  either  side  into 
the  angle  between  the  pericardium  and  the  lungs,  or  rather  pleurae. 
The  time  of  complete  atrophy  is  extremely  variable.  I  have  seen 
it  both  present  and  absent  in  autopsies  at  every  year  from  the  third 
to  puberty. 

THE  HEART.— At  birth,  the  anatomy  of  the  heart  still  shows 
the  peculiarities  required  by  the  fetal  circulation.  Functionally, 
with  the  tying  of  the  cord  and  the  expansion  of  the  lungs,  the  circu- 
lation of  the  blood  immediately  changes  to  the  course  seen  in  adults, 
although  a  small  amount  of  blood  may  still  pass  through  the  fora- 
men ovale  and  the  ductus  arteriosus.  Anatomically  the  changes  are 
of  course  not  immediate,  though  they  take  place  fairly  rapidly  after 
birth.  The  ductus  venosus  becomes  a  fibrous  cord  in  from  two  to 
five  days.  While  the  intrauterine  function  of  the  eustachian  valve 
ceases  immediately,  its  remains  can  be  found  for  an  indefinite  period. 
The  foramen  ovale  usually  is  closed  by  the  tenth  day,  although  it  is 
sometimes  found  open  either  as  a  whole,  or  in  its  upper  portion,  at 
any  period  of  childhood,  without  any  murmur  or  other  physical 
sign.  The  ductus  arteriosus  normally  becomes  impervious  in  from 
four  to  ten  days.  The  cavities  of  the  umbilical  vein,  and  of  the 
upper  parts  of  the  umbilical  arteries,  are  obliterated  in  from  two 
to  five  days. 

As  soon  as  these  changes  from  the  fetal  condition  are  completed, 
the  anatomy  of  the  heart  differs  in  no  essential  particular  from  that 
of  adults.  Its  growth  is  always  more  or  less  proportionate  to  the 
growth  of  the  child. 

THE  LUNGS. — The  age  at  which  the  lungs  reach  their  full  expan- 
sion forward  is  very  variable;  it  is  certainly  not  earlier  than  the 
sixth  year,  and  may  be  much  later.  There  is,  of  course,  a  continuous 
increase  in  the  relative  size  of  the  lungs  to  the  heart,  which  keeps 
pace  with  the  development  of  the  thorax. 

The  marked  anatomical  peculiarities  seen  in  the  lung  of  the  new- 
born infant  persist  almost  unchanged  throughout  the  first  year.  The 
alveolar  walls  remain  proportionately  thick,  the  connective  tissue 
stroma  remains  loose,  and  relatively  great  in  amount,  the  size  of 
the  alveolar  air  spaces  remains  small  in  proportion  to  that  of  the 


30 


The  Normal  Child 

Fig.  8 


Section  of  fetal  lung  at  5  months,  showing  development  of  bronchi;  no  alveoli 


Section  of  infant's  lung  at  10  months,  showing  increased  proportionate  amount  of 
parenchyma  in  comparison  with  the  fetal  condition;  distended  alveoli 


Normal  Development 


31 


bronchioles,  and  their  number  remains  relatively  small.  After  the 
first  year,  the  development  of  the  lung  begins  gradually  to  approach 
the  adult  type.  It  has  been  generally  stated  that  the  development 
is  complete  by  about  the  end  of  the  fourth  or  fifth  year.  I  beheve 
this  statement  to  be  only  partly  true.  At  this  age  the  size  of  the 
alveoli  has  attained  the  adult  proportion  to  the  bronchioles,  the 
walls  of  the  alveoli  have  become  thin,  and  the  stroma  has  become 
firm  and  binding.  But,  in  my  experience,  based  on  a  number  of 
observations  of  children's  lungs,  the  proportion  in  number  of  alveoli 
to  bronchioles  still  remains  smaller  than  the  adult  proportion,  and 
does  not  show  complete  development  until  toward  the  end  of 
childhood. 

THE  STOMACH.— Both  the  position  and  the  shape  of  the  stom- 
ach change  rapidly  during  the  first  year  of  life.  The  axis  of  the 
stomach  gradually  becomes  less  oblique,  and  by  the  end  of  infancy 
reaches  the  transverse  direction  seen  in  older  children  and  in  adults. 
The  fundus  develops  rapidly  during  the  first  year,  and  although  it 
does  not  reach  its  full  development  until  late  in  childhood  the  tubu- 
lar shape  of  the  organ  soon  disappears. 

The  development  of  the  capacity  of  the  stomach  is  important  in 
connection  with  the  subject  of  infant  feeding.  There  are  two  ways 
of  estimating  the  gastric  capacity.  One  is  based  on  actual  anatomic 
measurements  made  post-mortem.  The  other  is  based  on  measur- 
ing the  amount  of  fluid  which  a  normal  infant  takes  at  a  single  feed- 
ing. There  is  often  considerable  discrepancy  between  the  anatomic 
and  physiologic  measures  of  gastric  capacity.  The  following  table 
shows  some  anatomic  measurements  at  different  ages  made  by  Rotch 
and  Holt  respectively,  and  some  physiologic  measurements  made 
by  Rotch  and  Mosenthal  respectively: 


Birth 

1  week . . . 

2  weeks . . 

4  weeks . . 
8  weeks . . 

12  weeks. . 
1 6  weeks. . 

5  months. 

6  months. 

7  months. 

8  months. 

9  months. 

10  months. 

11  months. 
I  year . . . . 


Table  9 

Gastric  Capacity  in  Ounces 

Anatomical 
rotch  holt 

I.  20 


Physiological 
rotch     mosenthal 


90 


3-50 
4.00 
4.80 
4.80 

?.6o 


32  The  Normal  Child 

It  will  be  noted  that  the  figures  for  anatomic  gastric  capacity  given 
by  Rotch  and  by  Holt  are  fairly  close  to  each  other,  those  of  Holt 
being  in  general  slightly  larger  than  those  of  Rotch.  The  difference 
in  the  figures  can  easily  be  explained  by  some  minor  difference  in 
the  technique  of  taking  the  measurements.  The  figures  given  by 
Mosenthal  for  physiologic  capacity  are  much  larger  than  those 
of  Rotch.  This  can  probably  be  explained  on  the  ground  that  the 
babies  on  which  Mosenthal's  figures  were  based  were  given  all  the 
milk  they  would  take,  and  could  take  care  of,  whereas  Rotch's 
figures  are  based  on  babies  who  were  thriving  on  measured  amounts 
without  showing  signs  of  hunger.  The  amounts  given  to  these 
babies,  also,  were  more  or  less  based  on  Rotch's  anatomic  measure- 
ments. I  believe  Mosenthal's  figures,  which  show  the  physiologic 
capacity  to  be  larger  then  the  anatomic,  are  better.  The  reason 
for  the  physiologic  capacity  being  greater  than  the  anatomic  is  ex- 
plained by  recent  work  on  the  digestion  of  milk.  It  has  been  shown 
that  coagulation  begins  during  the  feeding,  and  the  passage  of  the 
fluid  portion  into  the  duodenum  begins  before  the  feeding  is  com- 
pleted. The  exact  bearing  which  measurements  of  gastric  capacity 
have  on  the  amounts  of  milk  to  be  given  at  a  feeding,  will  be  dis- 
cussed in  the  division  on  feeding. 

The  functional  development  of  the  stomach  is  so  closely  con- 
nected with  the  problems  of  digestion  and  nutrition  that  its  con- 
sideration will  be  postponed,  to  be  discussed  in  the  division  on  gastro- 
enteric diseases. 

THE  INTESTINE.— The  growth  of  the  small  intestine  is  so 
extremely  irregular  that  the  widest  variations  are  found  at  every 
age  of  childhood.  Its  most  rapid  and  constant  increase  in  length 
occurs  during  the  first  two  months  of  life.  The  variations  in  the 
rate  and  amount  of  its  growth  appear  to  bear  no  relation  to  the 
general  development  of  the  child. 

The  position  of  the  cecum  is  very  variable  in  infants  and  young 
children,  ranging  normally  from  the  lumbar  region  to  the  lowest 
part  of  the  iliac  fossa.  In  the  majority  of  instances  its  position 
is  higher  than  in  adults,  and  for  this  reason  the  ascending  colon  is 
very  short.  In  childhood,  especially  in  infants  and  young  children, 
the  ascending  colon  very  frequently  has. a  mesentery,  being  so  com- 
pletely invested  with  peritoneum  as  to  be  absolutely  free.  Both  the 
caecum  and  the  ascending  colon  are  always  much  more  freely  movable 
in  the  young  child  than  in  the  adult. 

The  length  and  direction  of  the  vermiform  appendix  are  so  very 
variable,  that  they  have  no  significance. 

The  descending  colon  usually  has  no  mesentery,  but  one  may 
be  present,  especially  in  early  infancy. 


Normal  Development  33 

During  the  first  four  months  of  life  there  is  Httle  or  no  change  in 
the  length  of  the  large  intestine  as  a  whole,  but  the  upper  portions 
grow  at  the  expense  of  the  sigmoid  flexure,  which  at  birth  has  a 
length  of  nearly  one-half  that  of  the  entire  large  intestine.  In  the 
majority  of  cases,  the  sigmoid  flexure  assumes  the  adult  proportion 
at  four  months,  but  sometimes  remains  relatively  very  long.  After 
the  age  of  four  months,  the  large  intestine  increases  in  length  through- 
out childhood,  until  the  adult  length  is  reached. 

THE  KIDNEYS.— The  fetal  lobulation  of  the  kidneys  observed 
at  birth  persists  for  a  variable,  but  considerable,  time.  It  is  usually 
found  at  autopsy  in  children  under  one  year.  Evidences  of  the 
uric  acid  infarction  usually  disappear  in  about  one  week,  but  I  have 
observed  them  at  autopsy  in  a  child  three  weeks  old. 

BONE  MARROW.— Nothing  definite  is  known  as  to  the  exact 
time  when  the  red  bone  marrow  of  early  life  changes  to  the  yellow 
marrow  of  a  later  period. 


IV.  HYGIENE  AND  CARE  OF  INFANTS 
AND  CHILDREN 

CARE  OF  THE  NEWBORN.— At  the  time  of.  ligating  and  cut- 
ting the  umbiHcal  cord,  the  physician  should  make  sure  that  the 
newborn  child  cries  lustily.  The  eyes  should  be  cleansed  with  sterile 
water,  but  the  mouth  should  not  be  washed.  In  hospital  practice, 
or  if  the  mother  has  had  a  vaginal  discharge,  a  few  drops  of  a  two 
per  cent,  solution  of  silver  nitrate  or  ten  per  cent,  argyrol  should  be 
instilled  into  the  eyes,  before  cleansing  them  with  water.  The  child 
may  then  be  wrapped  in  warm  flannels,  and  laid  aside,  until  the 
nurse  has  finished  the  immediate  care  of  the  mother. 

The  bath  should  then  be  given.  The  body  of  the  infant  should 
be  gently  rubbed  with  olive  oil,  to  soften  the  vernix  caseosa,  and 
then  bathed  in  warm  water  at  a  temperature  of  ioo°  F.  The  stump 
of  the  cord  and  the  surrounding  parts  should  be  carefully  dried,  and 
dusted  with  sterile  talcum,  or  other  dusting  powder.  The  cord 
should  be  wrapped  in  a  pad  of  sterile  gauze,  and  the  abdomen  should 
be  enveloped  rather  snugly  in  a  flannel  band.  The  infant  should 
then  be  examined  for  malformations  or  trauma  received  during 
birth,  after  which  it  may  be  dressed,  and  placed  in  its  crib.  It 
should  be  covered  with  blankets,  and  if  the  extremities  are  cold, 
or  if  the  lips  and  fingers  are  bluish,  hot  water  bottles  covered  with 
flannel  should  be  placed  in  the  crib,  care  being  taken  that  they  do 
not  come  in  contact  with  the  body.  The  baby  should  not  be  kept 
in  its  mother's  bed,  but  should  occupy  its  own  crib,  in  a  quiet,  dark- 
ened room. 

The  stump  of  the  cord  must  be  kept  dry,  and  should  not  be  dis- 
turbed any  more  than  is  necessary  to  inspect  it.  It  usually  sepa- 
rates from  the  fourth  to  the  seventh  day,  leaving  a  red  surface, 
which  rapidly  becomes  covered  with  epithelium.  The  umbilicus 
should  be  kept  dusted  with  sterile  talcum,  and  should  be  covered 
with  a  small  pad  of  sterile  gauze,  about  one-quarter  of  an  inch  thick. 

The  full  bath  should  not  be  given  until  after  the  umbihcal  scar 
has  healed.  Until  this  occurs,  the  infant  may  be  given  a  daily  sponge 
bath  at  a  temperature  of  ioo°  F.  Care  must  be  taken  that  all  the 
baths  at  this  early  period  of  infancy  be  given  in  a  warm  room. 

The  rectal  temperature  of  the  newborn  infant  should  be  taken 
twice  daily  until  the  umbihcus  has  healed.  All  the  intestinal  dis- 
charges should  be  saved  for  the  physician,  until  meconium  has  en- 
tirely disappeared.  The  baby  need  not  be  weighed  until  the  end 
of  the  first  week. 


Hygiene  and  Care  35 

The  feeding  of  the  newborn  baby  is  considered  in  the  division 
on  infant  feeding. 

WEIGHING. — Normal  babies  should  be  weighed  once  a  week 
during  the  first  year  of  life.  The  weighing  is  best  done  at  the  time 
the  infant  receives  its  daily  bath.  Infants  who  are  very  delicate, 
or  sick,  or  in  whom  some  change  in  the  feeding  has  been  instituted, 
should  be  weighed  daily,  unless  their  vitality  is  so  low  that  they 
constantly  have  a  subnormal  temperature.  During  the  second  year, 
it  is  also  better  to  weigh  most  babies  as  often  as  once  a  week,  although 
such  frequent  weighing  is  not  so  necessary  as  in  the  first  year.  Older 
children  should  be  weighed  once  a  month. 

BATHING. — Infants  and  children  must  be  bathed  daily.  In- 
fants should  begin  to  have  tub  baths  as  soon  as  the  cicatrix  of  the 
cord  has  healed.  Theoretically  the  best  time  for  the  tub  bath  is  in 
the  morning,  but  giving  it  at  this  time,  in  most  households,  does  not 
fit  in  so  well  with  the  child's  general  routine.  The  baby  usually  has 
to  have  its  first  feeding  upon  waking  in  the  morning,  and  often  goes 
out  shortly  after  the  second  feeding.  Also,  in  many  households  the 
rooms  are  not  warm  enough  to  bathe  the  baby  so  early  in  the  morn- 
ing. In  most  households  it  is  found  more  convenient  to  give  the 
tub  bath  at  night,  at  bed-time,  just  before  the  feeding  which  is  given 
about  six  o'clock.  The  baby  may  have  a  basin  bath  in  the  morning, 
before  its  second  feeding.  Even  if  no  basin  bath  is  given  at  this 
time,  the  infant's  face  should  be  washed. 

The  temperature  of  the  bath  at  the  different  ages  is  shown  in 
the  table. 

Table  io  .  " 

Temperature  of  the  Bath  for  Different  Ages 

AGE  CENTIGRADE    FAHRENHEIT 

At  birth 37.8°  100° 

During  first  three  or  four  weeks 35  °  95° 

One  to  six  months 34  °  93-2° 

From  six  to  twelve  months 32.2°  90° 

Twelve  to  twenty-four  months •  30  °  86° 

Then  gradually  reduce  in  summer  to 26.6°  80" 

In  the  third  or  fourth  year,  if  possible,  reduce  to 23.8°  75° 

The  temperature  of  the  room  in  which  the  bath  is  given  should 
be  from  76°  F.  to  80°  F. 

The  nurse  should  first  wash  the  face  in  clear  water,  keeping  the 
body  and  limbs  wrapped  up  in  a  warm  blanket.  The  face  is  then 
wiped  with  a  soft  towel.  She  should  gently  cleanse  the  nose,  the 
corners  of  the  eyes,  and  the  external  ears.  The  nose  is  especially 
important,  for  the  infant's  vitality  is  easily  aft'ected  by  occluded 
nares.     The  nurse  should  then  soap,  wash  off,  and  dry  the  scalp. 


36  The  Normal  Child 

Especial  care  should  be  paid  to  the  folds  of  the  neck,  the  axillae, 
groins,  genitals,  and  anus.  The  body  and  limbs  having  been  thor- 
oughly and  quickly  soaped,  the  nurse  should  gently  lower  the  infant 
with  its  face  up  into  the  clear  water  in  the  bath,  being  careful  not 
to  frighten  it  or  to  drop  it.  After  allowing  the  infant  to  kick  and 
splash  for  a  few  seconds,  it  is  taken  back  into  the  nurse's  lap  and 
carefully  dried  with  a  warm,  soft  towel.  When  the  skin  is  perfectly 
soft,  clear,  and  in  a  normal  condition,  no  powder  is  needed.  Where 
there  is  any  slight  irritation,  which,  at  times,  is  liable  to  occur  when 
the  skin  has  not  been  kept  sufficiently  dry,  especially  if  there  is  a 
decided  redness  in  the  folds  of  the  skin,  as  of  the  neck,  axillae,  or 
groins,  powder  may  be  applied. 

During  the  second  year,  the  tub  baths  at  night  are  continued, 
but  in  addition  sponge  baths  in  the  morning  should  become  part  of 
the  general  routine.  At  first,  the  temperature  of  the  water  may  be 
little  if  any  lower  than  that  of  the  tub  baths,  but  after  the  end  of  the 
second  year,  an  effort  should  be  made  to  make  the  morning  sponge 
baths  colder.  The  baths  must  be  very  brief.  The  child  should  stand 
in  a  tub  partly  filled  with  warm  water,  and  should  be  sponged  all 
over  very  rapidly  with  the  cooler  water,  for  not  more  than  half  a 
minute.  It  should  then  be  dried  by  vigorous  rubbing.  The  temper- 
ature of  the  water  used  in  giving  the  morning  douche,  at  first  70°  F., 
is  gradually  lowered,  until  the  temperature  of  ordinary  tap  water  is 
reached.  At  all  times  care  must  be  taken  that  children  react  thor- 
oughly from  these  baths.  If  at  any  time,  after  them,  children  shiver, 
look  pale,  or  become  slightly  blue  about  the  lips,  the  water  used  must 
be  warmer,  or  cold  sponging  must  not  be  used. 

In  the  latter  part  of  childhood,  the  warm  bath  at  night  should 
be  omitted,  except  occasionally.  At  this  time  every  morning,  the 
child,  standing  on  a  bath  mat,  should  be  thoroughly  washed  with 
warm  water,  and  may  then  plunge  into  a  tub  of  cooler  water.  The 
temperature  of  the  cold  plunge  should  be  not  over  70°  F,,  and  should 
be  as  much  colder  as  the  reaction  of  the  child  will  allow. 

CARE  OF  THE  MOUTH  AND  TEETH.— The  teeth  of  the 
young  infant  should  be  cleansed  each  morning,  when  the  morning 
toilet  is  made.  Too  much  vigor  must  not  be  used  in  the  mouth. 
Children  should  be  taught  to  use  the  toothbrush  at  the  earhest 
possible  moment. 

A  protest  should  be  made  against  the  way  in  which  the  nurse, 
and  also  others  who  come  near  the  infant,  put  their  fingers  into 
its  mouth  on  all  occasions.  It  would  seem  as  though  the  infant's 
mouth  was  considered  by  those  who  ought  to  know  better  as  some- 
thing especially  made  to  be  felt.  The  fingers  should  always  be 
thoroughly  washed  before  entering  an  infant's  mouth. 


Hygiene  and  Care  37 

A  nurse  should  be  instructed  that  she  is  never  to  kiss  the  infant 
on  the  mouth,  or  allow  any  one  else  to  do  so.  The  micro-organisms 
of  disease  can  well  be  transmitted  in  this  way.  Nor  should  the 
baby's  hands  or  fingers  be  kissed,  as  they  are  constantly  going  into 
its  mouth. 

CARE  OF  THE  SKIN.— The  skin  of  the  young  infant  is  very 
delicate,  and  exceedingly  liable  to  irritation.  Napkins  should  be 
removed  as  soon  as  soiled  and  wet.  In  very  fat  infants,  or  whenever 
there  is  the  slightest  sign  of  irritation  of  the  skin,  some  infant  powder, 
containing  stearate  of  zinc,  starch,  or  talcum,  should  be  used,  espe- 
cially in  the  folds  and  about  the  genitals.  Intertrigo  and  eczema  are 
usually  due  to  faulty  care  of  the  skin.  Children  who  perspire  freely 
at  night,  should  have  the  position  of  the  head  on  the  pillow  changed 
occasionally,  as  facial  eczema  may  be  produced  by  the  child's  face 
resting  all  night  on  a  sweat-soaked  pillow. 

CARE  OF  THE  GENITALS.— In  girls,  cleanliness  is  the  only 
requirement.  In  boys,  the  prepuce  must  be  attended  to,  and  the 
best  time  is  the  early  weeks  of  infancy.  In  most  cases  the  prepuce 
is  adherent  to  the  glans,  and  sometimes  it  is  very  long,  with  only 
a  pin-hole  opening.  This  condition  is  a  marked  source  of  discom- 
fort and  reflex  irritation,  from  accumulation  of  secretions.  When 
the  prepuce  is  very  long,  and  very  tightly  adherent,  circumcision 
should  be  performed.  I  am  not,  however,  an  advocate  of  circum- 
cision in  all  cases.  In  many  cases,  where  the  prepuce  is  compara- 
tively short,  the  adhesion  should  be  broken,  and  the  prepuce  retracted 
daily,  with  cleansing,  and  the  application  of  a  little  vaseline. 

CARE  OF  THE  HAIR.— Parents  do  not  usually  seek  the  advice 
of  the  physician  as  to  whether  the  child's  hair  should  be  cut  long 
or  short.  In  cases  where  the  parents'  aesthetic  feelings  lead  them 
to  keep  the  children's  hair  long,  the  physician  should  point  out  the 
sanitary  reasons  for  keeping  it  short.  Long  hair  makes  the  children 
perspire  about  the  head  and  neck  while  active,  and  increases  their 
chance  of  taking  cold  while  quiet.  It  makes  them  hot,  uncomfort- 
able, and  restless  at  night.  Short  hair  causes  a  better  growth  of 
hair  in  later  life. 

CLOTHING. — In  clothing  the  young  infant,  there  are  two  impor- 
tant requisites.  The  clothing  must  be  sufhciently  warm  to  protect 
the  infant  from  exposure,  and  it  must  be  so  arranged  as  to  allow 
the  most  perfect  freedom  of  motion  for  the  legs  and  arms,  and  for 
the  abdominal  and  respiratory  muscles.  Young  infants  have  a 
greater  body  surface  in  proportion  to  their  weight  than  have  older 
children  and  adults,  and  this  greater  surface  means  greater  oppor- 
tunity for  loss  of  heat  by  radiation.     Also,  the  heat  regulating  appa- 


38  The  Normal  Child 

ratus  of  the  infant  is  not  sufficiently  developed  to  maintain  so  early 
a  constant  temperature  under  varying  conditions  of  heat  and  cold. 
Infants,  then,  in  general,  require  warmer  clothes  than  older  children. 
The  community  in  general  is  so  thoroughly  impressed  with  the  neces- 
sity of  clothing  infants  warmly,  that  the  tendency  is  to  go  to  an 
extreme,  and  clothe  them  too  warmly.  The  physician  very  rarely 
has  to  order  warmer  clothes  for  the  infant,  but  frequently  finds  them 
dressed  too  warmly,  especially  during  the  summer  months,  and  when 
indoors  in  winter. 

The  ordinary  clothing  which  the  infant  wears  all  the  time  should 
be  designed  to  meet  the  conditions  prevailing  during  the  greater 
part  of  the  time  in  the  particular  season  of  the  year.  It  should  of 
course  be  lighter  in  the  warmer  than  in  the  colder  months.  It  rep- 
resents a  minimum  rather  than  a  maximum  of  clothing,  designed  so 
as  not  to  overheat  the  child,  but  to  keep  it  sufficiently  warm  under 
the  conditions  usually  prevailing.  Sudden  changes  to  a  colder  degree 
of  heat  surrounding  the  child,  such  as  when  the  child  goes  out  in 
winter,  or  when  the  temperature  falls  in  the  mornings  and  evenings 
of  summer,  should  be  met  by  extra  wraps.  On  the  hottest  days  of 
summer,  even  this  minimum  of  clothing  should  be  reduced,  and  the 
baby  should  be  allowed  to  play  and  kick  in  nothing  but  its  band 
and  diaper. 

The  clothes  must  be  loose,  so  that  they  do  not  interfere  with  the 
natural  activity  of  the  circulation,  do  not  press  or  bind  anywhere, 
and  do  not  interfere  with  full  muscular  activity.  All  the  clothes 
must  be  supported  from  the  shoulder,  and  not  from  the  waist.  They 
must  be  designed  to  go  on  and  come  off  easily.  For  this  purpose 
it  is  preferable  that  they  fasten  up  and  down  the  front  rather  than 
the  back. 

The  best  designed  clothes  which  I  have  seen  for  infants  are  called 
the  "Vanta  Vesta."  In  them  all  buttons  and  all  safetypins  are 
entirely  eliminated.  They  are  fitted  with  tapes,  which  are  so  placed 
as  to  fasten  them  in  exactly  the  best  manner,  and  the  tapes  can  be 
easily  changed  to  suit  the  size  of  the  particular  infant.  Even  the 
diapers  are  fastened  with  these  tapes. 

The  clothing  worn  by  the  infant  until  the  age  when  it  begins  to 
creep,  consists  of  the  following  articles:  The  flannel  abdominal  band 
is  often  worn  throughout  the  first  year.  It  is  not  a  necessity,  except 
for  the  first  few  months;  after  this  period  it  should  be  changed  for 
the  knitted  band,  which  fastens  to  the  diaper  below.  The  best 
material  for  this  band  is  silk  and  wool.  The  diaper  is  best  made 
of  birdseye  linen.  The  shirt  is  a  garment  with  sleeves  and  high 
neck,  and  is  almost  as  long  as  the  "gertrude"  and  dress.  It  should 
fasten  in  front  rather  than  behind.     It  is  woven,  the  best  material 


Hygiene  and  Care 


39 


Fig.  9 — Clothing  for  an  Infant 


First  step  in  the  dressing  of  a  baby,  showing  band,  diaper,  and  stockings 


Fig.  10 — Clothing  FOR  an  Infant 


Second  step  in  the  dressing  of  a  baby,  showing  the  shirt 


40 


The  Normal  Child 

Fig.  II — Clothing  for  an  Infant 


Third  step  in  the  dressing  of  a  baby,  showing  the  "Gertrude"  or  long  flannel 

petticoat 

Fig.  12 — Clothing  for  an  Infant 


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Final  step  in  the  dressing  of  a  baby,  showing  the  dress 


Hygiene  and  Care  41 

being  silk  and  wool.  The  petticoat,  or,  as  it  is  usually  called,  the 
"gertrude,"  goes  on  over  the  shirt.  It  has  a  low  neck  and  no  sleeves, 
is  somewhat  longer  than  the  shirt,  but  not  so  long  as  the  old-fash- 
ioned ''long  clothes"  in  which  the  infant's  feet  were  tightly  swathed, 
and  preferably  fastens  in  the  front.  It  may  be  made  either  of  fine 
flannel,  or  of  woven  silk  and  wool;  flannel  is  less  expensive,  and 
fully  as  satisfactory.  The  outer  garment  is  the  dress,  which  is  made 
of  some  soft,  white  material,  and  has  a  high  neck,  and  sleeves.  It 
is  of  the  same  length  as  the  gertrude.  Many  mothers  put  on  a 
soft  lawn  gertrude  between  the  dress  and  the  flannel  gertrude.  The 
dress  is  the  only  garment  which  the  nurse  should  be  allowed  to  put 
on  over  the  infant's  head.  The  band,  shirt,  and  gertrude  should 
always  be  put  on  over  the  feet,  and  if  they  open  in  front,  the  baby 
may  be  dressed  and  undressed  very  rapidly  and  easily.  The  young 
infant  does  not  need  to  wear  stockings,  except  sometimes  when  he 
goes  out  in  cold  weather.  There  is  no  objection  to  short,  knitted 
socks,  if  the  mother  wants  to  use  them.  The  nightdress  is  a  garment 
made  of  flannel,  or  of  woven  silk  and  wool,  which  goes  on  over  the 
shirt.  It  should  open  all  up  and  down  the  front,  and  the  back 
should  be  longer  than  the  front,  to  permit  of  its  being  folded  over 
the  feet. 

When  the  infant  begins  to  creep,  short  clothes  take  the  place  of 
the  long  clothes.  The  undershirt  now  takes  the  place  of  both  the 
shirt  and  band.  This  should  have  sleeves,  and  should  be  made  of 
silk  and  wool,  or  a  fine  all-wool  material.  The  flannel  petticoat 
is  made  of  the  same  material  as  in  earlier  infancy,  except  that  its 
waist  is  cotton;  it  has  still  a  low  neck  and  no  sleeves,  but  is  short, 
goes  on  over  the  head,  and  has  no  fastenings  either  in  front  or 
behind.  Over  it  goes  the  white  petticoat,  similar  in  design,  but 
made  of  some  soft,  white  material  with  a  cotton  waist.  Over  these 
garments  go  the  short  dress,  with  high  neck,  sleeves,  and  buttons 
behind.  Stockings  must  be  worn  at  this  period.  These  are  pre- 
ferably made  of  wool,  and  fasten  to  the  diaper.  When  the  child 
begins  to  stand  and  walk,  soft  kid  shoes  should  be  used.  Care  must 
be  taken  that  the  shoes  are  of  proper  shape,  adapted  to  the  natural 
curves  of  the  child's  foot.  At  night  the  child  should  wear  a  regular 
nightdress,  made  of  soft  flannel,  with  high  neck  and  long  sleeves, 
and  buttoned  behind. 

When  the  child  is  two  or  three  years  old,  and  often  before,  the 
diaper  is  discarded,  and  the  child  begins  to  wear  drawers.  At  this 
time  the  petticoats  no  longer  have  the  cotton  waists  permitting 
them  to  go  over  the  shoulders,  and  a  new  garment  is  worn,  called 
the  waist.  The  waist  has  no  sleeves,  but  is  supported  by  shoulder 
straps,  and  should  fit  loosely,  especially  about  the  child's  waist.     Its 


42  The  Normal  Child 

principal  function  is  to  support  the  petticoats,  drawers,  and  stockings. 
It  is  furnished  with  sufficient  buttons  at  the  waist,  to  permit  the 
petticoats,  drawers,  and  garters  to  be  fastened  to  it,  so  that  by  means 
of  this  waist,  everything  hangs  from  the  shoulders,  without  any 
constriction  anywhere. 

SLEEP. — The  amount  of  sleep  required  by  children  at  different 
ages  varies  very  much  with  the  individual.  The  newborn  infant 
sleeps  almost  continually,  waking  only  for  its  feedings,  and  during 
the  first  three  months,  it  sleeps  twenty  to  twenty-two  hours  out  of 
the  twenty-four.  It  sleeps  somewhat  less,  sixteen  to  eighteen  hours, 
during  the  second  three  months.  In  the  second  half  of  the  first 
year,  the  child  should  sleep  at  night  from  about  six  p.  m.  to  six  a.  m., 
and  should  have  two  two-hour  naps  during  the  day,  one  between 
nine  and  twelve  in  the  morning,  and  one  between  twelve  and  three 
in  the  afternoon.  The  periods  devoted  to  exercise,  amusement,  and 
play  should  be  between  six  and  nine  in  the  morning,  and  between 
three  and  six  in  the  afternoon. 

The  child  should  always  be  allowed  to  sleep  as  much  as  it  will. 
The  twelve-hour  sleep  at  night  should  be  continued  until  he  is  five 
or  six  years  old.  As  they  grow  older,  some  children  develop  the 
habit  of  waking  up  earlier  in  the  morning.  If  this  occurs,  the  hour 
of  their  bedtime  should  not  be  made  later,  as  this  will  disturb  their 
routine,  and  will  usually  not  correct  the  habit.  The  habit  may  often 
be  corrected  by  making  sure  that  the  nursery  is  kept  darkened  in 
the  morning. 

The  two  day  naps  should  be  continued  as  long  as  possible,  but 
are  usually  shortened  by  the  child  itself.  At  one  year,  the  morning 
nap  is  usually  shortened  to  one  hour,  and  is  given  up  in  the  last 
half  of  the  second  year.  The  afternoon  nap  should  be  continued, 
although  children  often  will  not  sleep  after  they  are  five  or  six  years 
old.  They  should,  however,  still  be  made  to  lie  down  and  rest, 
until  they  are  seven  or  eight. 

It  is  very  important  that  the  child  be  trained  from  birth  in  proper 
habits  of  sleep.  It  should  never  be  rocked  to  sleep,  and  preferably 
should  not  fall  asleep  in  its  mother's  or  nurse's  arms,  but  should 
be  accustomed  to  be  put  in  its  crib  alone,  in  a  quiet,  darkened  room, 
and  to  go  to  sleep  of  its  own  accord.  All  other  artificial  devices, 
such  as  allowing  it  to  go  to  sleep  on  the  breast,  or  with  a  nipple  in 
its  mouth  should  be  avoided.  Failure  to  go  to  sleep  properly  means 
noise,  light,  hunger,  indigestion,  or  wet  napkins. 

FRESH  AIR  AND  GOING  OUTDOORS.— Nothing  is  of  greater 
importance  in  insuring  the  normal  development  of  the  growing  child, 
and  in  the  prevention  of  disease,  than  abundance  of  pure,  fresh  air. 
This  prime  necessity  in  the  hygiene  of  early  life  is  more  neglected 


Hygiene  and  Care  43 

than  any  other,  usually  through  fear  of  making  the  children  ill  by 
exposure.  When  children  are  delicate  there  is  a  special  tendency  to 
deprive  them  of  the  fresh  air  which  they  especially  need. 

During  the  first  week  or  two  of  life,  a  baby  is  very  easily  dis- 
turbed by  changes  in  the  temperature,  and  by  exposure  to  cold  air. 
Its  nutrition  and  heat  regulating  apparatus  are  not  estabHshed,  and 
it  requires  coddling  and  warmth.  This  does  not  mean  that  the 
young  infant  is  not  to  be  kept  in  well  ventilated  rooms,  but  only 
that  it  is  not  to  go  out  doors,  nor  be  exposed  to  any  indoor  airing 
which  lowers  the  temperature  of  his  surroundings  below  about  70°  F. 

After  the  first  one,  two,  or  three  weeks  of  life,  when  the  regular 
routine  of  early  Hfe  has  become  estabHshed,  we  are  confronted  by 
the  question  of  providing  the  infant  with  additional  fresh  air,  by 
means  of  going  outdoors,  and  by  means  of  open  windows.  The 
transition  from  the  protected  routine  of  the  early  weeks,  to  that  of 
later  infancy  must  never  be  abrupt,  but  must  be  brought  about 
gradually.  The  proper  management  of  the  fresh  air  problem  depends 
upon  the  time  of  year. 

With  infants  who  are  born  in  the  summer  months,  there  is  no 
reason  why  they  should  not  begin  to  go  outdoors  after  the  first  week 
or  two.  The  infant  should  then  spend  as  much  time  as  possible  in 
the  open  air,  sleeping  outdoors  in  his  carriage  in  the  day  time.  When 
indoors,  the  windows  of  his  room  should  always  be  open.  In  summer, 
all  that  is  necessary  is  to  guard  against  the  very  sudden  drops  in  the 
temperature  which  are  sometimes  seen  at  our  summer  resorts.  At 
such  times,  the  infant  may  continue  to  go  out,  unless  the  tempera- 
ture falls  below  60°  F.,  but  extra  wraps  must  be  provided.  Also, 
when  indoors,  he  may  still  sleep  with  open  windows,  but  if  it  is  so 
cold  that  the  temperature  in  his  room  would  fall  below  60°  F.,  the 
windows  must  not  be  opened  so  wide.  Only  at  those  hours  when 
the  infant  is  bathed,  or  is  partially  undressed  and  allowed  to  kick 
and  play,  should  the  windows  be  closed. 

Infants  who  are  born  in  the  spring  or  autumn  should  not  begin 
to  go  outdoors  until  they  are  at  least  one  month  old,  and  then  should 
not  go  out  when  the  outdoor  temperature  is  below  60°  F.  They 
should  at  first  not  be  kept  out  more  than  ten  or  fifteen  minutes,  and 
the  duration  of  the  outing  should  be  lengthened  gradually.  With 
infants  who  begin  to  go  out  in  the  autumn,  it  is  possible  to  continue 
to  take  them  out  even  as  the  season  advances,  if  care  is  taken  that 
they  be  kept  in  on  the  colder  days,  and  that  they  be  exposed  very 
gradually  to  a  lower  outdoor  temperature,  so  that  often  they  may 
continue  to  go  out  on  favorable  days  all  winter. 

In  spring  and  autumn  infants  must  be  gradually  accustomed  to 
open  windows  in  their  sleeping  rooms  after  they  are  a  month  old, 


44  The  Normal  Child 

precautions  being  taken  against  sudden  falls  in  the  temperature  of 
their  sleeping  rooms. 

^Vhen  infants  are  born  in  the  late  autumn  or  winter,  it  is  more 
difficult  to  provide  plenty  of  fresh  air  without  too  sudden  a  tran- 
sition. When  they  are  a  month  old,  they  may  begin  to  have  indoor 
airings.  They  are  dressed  for  an  outing,  and  then  the  windows  of 
the  room  are  opened  wide  for  a  few  minutes.  The  minimum  tem- 
perature of  the  room  must  be  lowered  very  gradually,  while  the  dura- 
tion of  the  airing  is  very  gradually  increased.  This  substitute  for 
an  outing  may  be  continued  through  the  winter  months,  and  the  child 
will  be  ready  for  an  actual  outdoor  airing  with  the  first  fine  days  of 
spring.  After  these  indoor  airings  are  instituted,  the  child  may  be 
gradually  accustomed  to  sleeping  in  a  room  with  open  windows,  the 
window  at  first  being  opened  only  the  merest  crack,  and  gradually 
opened  more  on  the  warmer  nights. 

When  an  infant  is  four  or  five  months  old,  he  should  go  out  doors 
even  in  winter.  In  our  middle  and  northern  states,  the  weather 
conditions  are  such  that  it  is  not  advisable  for  infants  to  be  taken 
out  every  day.  When  it  is  very  windy  and  dusty,  when  there  is 
a  snow  storm,  when  the  snow  is  melting,  and  when  the  temperature 
is  below  20°  F.,  it  is  better  for  the  infant  to  receive  his  airing  indoors. 
On  fine,  calm,  sunny  days,  even  if  fairly  cold,  he  should  go  out  for 
two  hours  in  the  morning,  and  for  two  hours  in  the  afternoon,  but 
in  winter,  should  not  be  out  later  than  three  o'clock.  The  best 
times  for  these  outings  are  from  ten  to  twelve  in  the  morning,  and 
from  one  to  three  in  the  afternoon.  There  is  absolutely  no  objection 
to  an  infant  sleeping  outdoors  in  his  carriage  in  winter.  The  nurse 
should  protect  his  eyes  from  the  direct  rays  of  the  sun,  and  his  face 
from  dust  and  strong  wind. 

Older  children  should  be  outdoors  as  much  as  possible,  being  kept 
in  only  when  the  outdoor  weather  conditions  are  very  bad. 

As  long  as  an  infant  spends  most  of  his  time  in  bed  while  indoors, 
it  is  easy  to  keep  the  windows  of  his  nursery  open,  and  still  protect 
him  from  exposure  to  draughts.  When  he  has  grown  older,  and  has 
reached  the  age  when  he  begins  to  creep,  stand,  walk,  and  play,  this 
is  more  difficult  in  the  colder  months.  The  child  will  play  on  the 
floor,  and  if  the  window  is  open,  no  matter  how  carefully,  and  even 
if  a  window  board  is  used,  there  are  sure  to  be  cold  draughts  on  the 
floor.  In  most  cases  it  is  impossible  to  keep  the  window  of  the 
nursery  open,  even  with  a  window  board,  while  the  child  is  playing. 
I  am  a  great  believer  in  an  open  fire,  which  is  a  great  aid  to  ventila- 
tion, and  from  the  draught  of  which  the  child  may  be  protected  by 
not  alloAving  him  to  play  in  a  direct  line  between  the  window  and 
the  fireplace.     In  any  case,  the  nursery  should  always  be  thoroughly 


Hygiene  and  Care  45 

aired  whenever  the  child  is  out  of  it,  and  before  he  goes  to  bed  at 
night.  In  the  day  time,  if  possible,  he  should  be  changed  from 
one  well,  aired  room  to  another. 

The  practice  has  frequently  been  adopted  in  cases  where  infants 
were  born  in  summer,  and  have  become  accustomed  to  sleeping 
outdoors  even  at  night,  to  continue  having  them  sleep  in  an  outdoor 
sleeping-porch  even  in  winter.  I  have  seen  this  practice  adopted 
without  harm,  and  apparently  with  benefit.  Great  care  must  be 
taken  with  the  coverings,  and  constant  vigilance  exercised  against 
sudden  changes  in  the  weather.  It  is  so  difficult  in  our  northern 
climate  to  care  for  children  sleeping  outdoors  at  night  in  winter, 
that  I  do  not  recommend  it  until  children  are  at  least  three  years 
old.  The  nursery  with  open  window  provides  enough  fresh  air  for 
the  average  baby.  After  the  age  of  three,  I  am  a  great  believer  in 
the  outdoor  sleeping-porch,  whenever  it  can  be  provided. 

EXERCISE. — In  young  infants  exercise  is  obtained  by  kicking 
its  legs,  and  waving  its  arms,  and  does  not  require  any  very  special 
attention.  It  is,  however,  a  bad  plan  to  allow  infants  to  lie  in  their 
cribs  all  the  time.  This  fault  is  more  often  seen  in  hospitals  than 
in  private  practice,  and  sometimes  leads  to  marked  impairment  of 
the  health  of  the  baby.  The  babies  must  be  picked  up  and  carried 
about  occasionally  and  their  position  should  be  frequently  changed. 
In  private  practice  it  is  a  good  plan,  once  or  twice  a  day,  to  take 
the  baby  into  a  warm  room,  remove  its  more  cumbersome  outer 
clothing,  and  let  it  kick  about  for  a  while  on  a  large  bed. 

When  the  babies  grow  older,  and  reach  the  age  when  they  begin 
to  creep,  they  normally  never  fail  to  take  sufficient  exercise,  and 
sometimes  take  too  much  unless  they  are  restrained.  By  placing 
them  on  the  floor  on  a  large  mattress,  or  on  a  large  bed,  in  a  warm 
room,  opportunity  may  be  given  then  to  kick  and  roll  about  as  much 
as  they  desire. 

After  babies  have  learned  to  walk,  care  must  be  taken  to  prevent 
them  over-exerting  to  the  point  of  becoming  tired.  Exercise  in  the 
open  air  is  best,  but  they  must  not  be  allowed  to  walk  too  far.  It 
is  better  to  wheel  them  to  some  desirable  spot,  and  then  let  them 
walk  or  run  about  for  a  time  which,  short  at  first,  is  gradually  in- 
creased as  they  grow  older,  until  finally,  between  three  and  five  years 
of  age,  they  walk  during  the  entire  outing.  For  indoor  exercise  in 
winter,  an  exercise  pen,  which  keeps  them  off  the  floor,  is  often  useful. 

In  older  children,  every  form  of  outdoor  exercise  should  be  en- 
couraged. In  normal  children,  none  of  the  usual  games  and  sports 
are  harmful,  and  opportunity  should  be  given  for  the  children  to 
learn  and  practice  as  many  as  possible. 


46  The  Normal  Child 

HYGIENE  OF  THE  NERVOUS  SYSTEM.— It  must  be  remem- 
bered that  the  nervous  system  is  relatively  undeveloped  throughout 
the  whale  of  infancy  and  childhood.  The  first  two  years  of  life 
constitute  the  period  in  which  the  brain  grows  more  rapidly 
than  during  all  the  rest  of  the  chi'd's  Hfe.  This  rapidly  growing 
brain  requires  above  all  things  rest  and  peace,  and  is  especially 
sensitive  to  abuse.  At  all  times  the  nervous  system  of  early  life 
is  unstable,  and  extremely  sensitive  to  stimulat'on  and  prone  to 
excessive  reaction.  It  is  sensitive  both  to  reflex  stimulation,  and  to 
mental  stimulation. 

To  insure  normal  development  of  the  nervous  system,  care  must 
be  taken  at  every  age  that  there  is  present  no  source  of  reflex  irri- 
tation. The  physician  should  carefully  examine  all  children  who 
come  under  his  care  for  evidences  of  such  conditions  as  phimosis, 
adherent  prepuce  or  clitoris,  adenoid  disease,  eye-strain,  chronic 
indigestion,  and  others.  The  removal  of  any  such  possible  cause 
of  reflex  injury  to  the  nervous  system  is  very  important. 

Mental  over-stimulation  is  still  more  common  as  a  source  of  injury 
to  the  growing  child.  It  may  easily  be  begun  and  carried  to  an 
injurious  extent  in  the  earlier  months  of  infancy,  without  the  mother 
being  aware  that  any  harm  is  being  done.  For  the  young  baby, 
the  chief  form  of  over-stimulation  which  its  nervous  system  receives, 
is  too  much  or  too  active  entertainment.  In  most  famihes  the  first 
baby  is  the  greatest  sufferer,  from  parents  at  least;  but  often  subse- 
quent babies  are  allowed  to  become  the  plaything  of  the  older  chil- 
dren. Babies  should  not  be  played  with  much.  If  possible  they 
should  not  be  allowed  to  pass  their  time  in  rooms  where  the  activi- 
ties of  family  Ufe  are  a  constant  source  of  noise,  and  where  they  are 
constantly  attracting  superfluous  attention.  A  proud  mother  likes 
to  show  off  her  baby  to  visitors  and  friends,  who  like  to  hold  it,  and 
hand  it  about,  and  poke  it  to  make  it  smile,  and  talk  to  it.  As  it 
begins  to  react  more  and  more  to  its  surroundings,  by  smihng,  wrig- 
ghng,  and  kicking,  these  actions  are  considered  "cunning,"  and  more 
and  more  efforts  are  made  to  bring  them  forth.  All  this  is  very 
bad  for  the  baby.  It  is  possible  to  produce  in  a  very  young  baby  an 
actual  condition  of  nervous  exhaustion,  which  first  manifests  itself 
by  failure  to  gain  weight,  then  by  loss  of  appetite,  than  by  restless- 
ness and  poor  sleep,  the  baby  jumping  at  the  slightest  sound. 

Even  with  older  infants  and  children,  the  nervous  system  can 
very  easily  be  over-stimulated  to  the  extent  of  producing  symptoms 
of  harm.  Children  are  sometimes  amused  by  exciting  and  unusual 
sights  and  sounds.  Violent  romping  games,  especially  at  night,  and 
suggesting  new  and  exciting  forms  of  play,  are  also  bad.  It  is  better  to 
allow  children  to  invent  their  own  play,  than  to  play  with  them  too 


Hygiene  and  Care  47 

much.  Moreover,  especially  when  the  children  are  bright  and  learn 
easily,  their  fond  parents  often  delight  in  teaching  them  little  sayings, 
or  rhymes,  at  too  early  an  age.  This  is  also  too  stimulating  to  the 
nervous  system  of  the  young  child,  and  the  brighter  the  child,  the 
greater  the  danger.  The  telHng  of  exciting  stories,  or  of  stories  about 
unfamiliar  things  which  vividly  stimulate  the  imagination,  is  also  bad. 
Too  much  adult  companionship  is  often  not  good  for  children,  espe- 
cially if  new  things  are  taught  and  suggested.  The  young  child  learns 
best  from  the  companionship  of  other  children  of  the  same  age.  The 
type  of  the  individual  child  should  be  considered.  There  is  more 
danger  from  over-stimulation  from  teaching,  novelty,  and  excitement 
in  the  bright  child,  than  in  the  dull  and  phlegmatic  child. 

When  they  get  older,  the  question  of  kindergarten  and  school 
arises.  When  a  child  has  reached  the  age  of  six  years,  I  believe  that 
kindergarten  is  a  good  thing,  provided  that  it  is  properly  managed, 
with  a  maximum  of  play  and  exercise  for  the  hands  and  body,  and  a 
min'mum  of  teaching  and  exercise  for  the  mind  and  eyes.  The 
chief  value  of  kindergarten,  however,  is  the  companionship  of  other 
children  of  the  same  age. 

School  is  the  next  step  after  kindergarten.  I  believe  that  all 
children  who  have  attained  the  proper  mental  and  physical  develop- 
ment, should  go  to  school  with  other  children,  and  should  not  have 
private  lessons  at  home.  Private  teaching  by  a  governess  does  not 
satisfy  the  very  real  need  for  companionship.  At  just  what  age  a 
child  should  begin  to  go  to  school,  and  for  how  long,  are  questions 
which  vary  with  the  individual.  At  no  time  during  childhood  should 
school  interfere  with  the  large  amount  of  outdoor  exercise  which  is 
so  essential  to  proper  development  in  childhood.  The  hours  of  the 
public  schools  in  many  parts  of  this  country,  with  two  daily  ses- 
sions, I  believe  to  be  too  long. 

The  physical  development  of  the  child  is  very  important  in  con- 
nection with  the  question  of  school.  It  has  been  shown  that  a 
child's  capacity  for  mental  work  without  injury  to  health,  bears  a 
direct  relation  to  his  physical  development.  The  difficulty  lies  in 
measuring  the  physical  development;  height  and  weight  alone  can- 
not form  the  criteria  on  which  the  estimate  is  based.  Everything, 
all  the  evidence  obtained  by  careful  physical  examination,  should 
be  considered.  Rotch  suggested,  as  the  best  measure  of  develop- 
ment, the  successive  times  of  ossification  of  the  carpal  bones,  and 
has  designed  a  scheme  which  he  called  the  ''anatomic  index."  This 
has  proved  a  very  satisfactory  basis  in  places  where  large  numbers 
of  children  have  to  be  grouped  and  classified  according  to  their 
stage  of  development. 

Some  of  the  dangers  and  disadvantages  of  many  of  our  school 


48  The  Normal  Child 

systems  are  the  following: — In  the  first  place,  there  is  the  danger 
of  too  long  hours.  A  second  unfavorable  feature  often  found  in 
school  life,  is  the  fostering  of  a  spirit  of  competition,  by  means  of 
marks  and  prizes.  There  is  another  danger  which  pretty  and  pre- 
cocious children  in  particular  encounter,  that  of  becoming  "teachers' 
pets."  These  children  are  encouraged  to  seek  promotion,  and  are 
shown  off,  and  speak  their  little  pieces  whenever  visitors  are  in  the 
school.  Many  a  nervous  system  has  been  injured  in  childhood  by 
the  over-ambitious  teacher. 

Precocity  in  children  is  always  a  sign  that  mental  development 
should  be  guarded  and  restrained,  rather  than  fostered.  The  life 
of  the  young  child  should  always  be  more  like  the  life  of  the  young 
animal  than  like  that  of  the  adult.  Children  are  little  animals, 
not  little  men  and  women. 

TRAINING  AND  DISCIPLINE,  HABITS.— Children  may  fre- 
quently be  trained  to  control  the  rectum  and  bladder  at  a  remark- 
ably early  age.  Such  training  should  always  be  begun  before  the 
end  of  the  first  year  of  life.  The  mother  should  observe  at  what 
hour  the  baby  usually  has  a  movement  of  the  bowels,  which  in  most 
cases  follows  very  shortly  after  a  feeding,  and  the  mother,  imme- 
diately after  this  particular  feeding,  should  put  the  baby  on  a  small 
chamber.  Many  children  learn  very  quickly  to  indicate  when  they 
want  to  have  a  movement.  The  training  of  the  bladder,  while 
rather  less  rapid,  can  be  carried  out  in  the  same  way.  Children 
vary  very  much  as  to  how  quickly  they  learn  to  give  signs  when 
they  want  the  chamber,  but  many  intelligent  children  learn  so  quickly, 
that  in  the  second  year  napkins  can  be  dispensed  with  during  the  day. 

While  children  are  very  young,  no  other  habits  should  be  taught 
by  training,  except  the  control  of  the  rectum  and  bladder.  During 
this  early  period  of  life,  efforts  at  training  should  be  directed  at  pre- 
venting the  development  of  bad  habits. 

The  earliest  of  these  habits  to  appear,  and  one  of  the  commonest, 
is  crying.  The  crying  habit  develops  in  infants  who  are  picked  up 
and  held  and  petted,  or  talked  to  and  amused,  whenever  they  cry. 
The  cause  of  the  first  crying  may  have  been  something  really  wrong, 
but  if  crying  is  treated  by  picking  up  and  amusing  the  baby,  the 
habit  will  persist  after  the  cause  is  no  longer  present.  It  must  be 
remembered  that  it  is  a  good  thing  for  the  young  infant  to  cry  a 
litt  e  every  day,  crying  having  a  beneficial  effect  in  providing  exer- 
cise, favoring  peristalsis,  and  causing  deep  inspiration  and  good 
expansion  of  the  ungs.  Too  much  crying  in  a  well  and  unspoiled 
baby,  always  indicates  that  something  is  wrong,  or  at  least,  that 
some  cause  exists  which  can  be  removed.  An  infant  cries  from 
hunger,   from  indigestion,   from  fright,   from   soiled  napkins,   from 


HYGIE^^E  AND  Care  49 

inflamed  buttocks,  from  tight  clothes.  In  all  cases  the  crying 
should  not  be  treated  by  picking  the  baby  up  and  diverting  him, 
but  a  painstaking  search  for  the  cause  should  be  instituted,  and 
we  should  not  be  satisfied  till  it  has  been  found  and  removed.  The 
baby  who  cries  violently,  but  stops  abruptly  as  soon  as  picked  up, 
has  become  an  habitual  cryer,  and  has  advanced  the  first  step  on 
the  road  which  leads  to  the  '^  spoiled  child."  Such  cases  must  be 
treated  by  a  short  period  of  rigid  discipKne.  If  for  a  few  times  he 
is  left  to  "cry  it  out,"  he  will  be  cured.  Mothers  should  be  assured 
that  this  treatment  will  not  injure  the  baby's  nervous  system  as 
much  as  allowing  the  habit  to  continue,  and  that  it  will  not  cause 
either  convulsions  or  rupture. 

The  crying  habit  is  almost  identical  with  another  bad  habit,  that 
of  being  held  constantly  in  the  arms.  A  baby  should  be  handled  as 
little  as  possible,  just  enough  to  give  it  exercise.  It  should  never 
be  allowed  to  fall  asleep  in  its  mother's  or  nurse's  arms.  The  habit 
of  being  held  soon  develops,  and  leads  to  the  crying  habit  Its  treat- 
ment is  the  same,  when  developed,  but  it  may  always  be  prevented. 

Another  habit,  more  inexcusable  on  the  part  of  the  mother  or 
nurse,  is  that  of  sucking  on  a  rubber  nipple  or  ''pacifier."  Besides 
deforming  the  lips  and  jaws,  the  pacifier  is  always  unsanitary.  Thumb 
and  finger  sucking  are  bad  habits  of  a  similar  character,  and  the  habit 
of  pulling  the  ears  is  sometimes  seen.  These  can  be  cured  by  band- 
aging the  hands,  and  in  the  case  of  thumb  and  finger  sucking,  putting 
a  solution  of  quinine  on  the  bandage.  All  sorts  of  curious  rare  habits 
are  sometimes  seen  in  children  otherwise  normal.  One  child  I  have 
seen  recently  has  a  habit  of  deliberately  banging  one  part  of  his 
cranium  against  the  bars  of  his  crib. 

The  training  of  children  in  habits  of  good  conduct  and  behavior, 
is  as  important  as  it  is  difficult.  While  they  are  very  young,  and 
unable  to  understand  at  all  the  meaning  of  right  and  wrong,  it  is 
absolutely  useless  to  use  either  admonition  or  scolding.  Fortunately, 
at  this  age,  the  properly  cared  for  child  will  not  be  able  to  do  very 
many  things  which  are  injurious.  If  he  does  begin  to  do  things  which 
are  a  real  menace,  such  as  pulling  down  table  cloths,  or  putting  beans 
and  shoe-buttons  into  his  nose,  he  must  be  corrected  physically. 
At  this  age  the  baby  is  precisely  like  a  young  animal.  Young  ani- 
mals learn  the  art  of  selfpreservation  through  the  pain  which  attends 
their  dangerous  acts,  and  kittens  or  puppies  do  not  walk  into  the 
fire.  For  young  children  who  are  beginning  dangerous  habits,  there 
is  nothing  like  a  good  spanking.  The  mother  often  fears  that  the 
child  will  dread  her  instead  of  loving  her,  but  if  the  spanking  always 
immediately  follows  the  wrong-doing,  and  if  the  punishment  is  never 
remitted,  but  always  carried  out,  this  will  never  occur. 
4 


50  The  Normal  Child 

For  oMer  children,  much  depends  on  a  proper  method  of  disci- 
pHne.  When  children  are  old  enough  to  understand  commands,  they 
must  be  trained  to  be  obedient,  and  discipline  must  be  carried  out 
in  the  way  which  will  cause  the  least  stimulation  to  the  sensitive 
nervous  system  of  the  young  child.  All  punishment,  at  this  age, 
should  if  possible  be  made  to  take  the  form  of  deprivation  of  a  pleas- 
ure. The  daily  life  of  the  young  child  has  by  this  time  become  so 
varied,  that  some  parts  of  the  daily  routine  are  looked  forward  to 
and  enjoyed  more  than  others.  These  times  of  enjoyment  should  be 
taken  away  when  the  child  is  naughty.  But  the  great  secret  of 
carrying  out  this  discipHne  properly,  is  to  make  each  deprivation 
appear  from  the  start  as  the  natural  and  inevitable  consequence  of 
the  naughty  act.  Each  wrong-doing  should  be  surely  followed  by 
its  particular  deprivation.  It  is  essential  that  these  punishments  be 
never  remitted  under  any  circumstances.  The  mother  in  her  affection, 
and  desire  to  make  her  child  happy,  is  strongly  tempted  to  let  the  child 
off,  if  he  will  "be  good  next  time."  This  is  very  bad.  The  penalty 
should  appear  to  the  child  as  coming  inevitably,  through  the  laws  of 
nature,  the  mother  being  unable  to  prevent  it.  Once  the  penalty  is 
remitted,  it  becomes  for  the  child  the  arbitrary  act  of  the  mother, 
dependent  upon  her  will,  and  the  child  will  exercise  every  form  of 
ingenuity  to  be  as  naughty  as  possible,  and  yet  escape  punishment. 

Parents  should  of  course  never  show  anger,  irritation,  or  annoy- 
ance in  punishing  children.  They  should  never  under  any  circum- 
stances bribe  children  to  be  good  with  rewards  or  special  pleasures; 
this  is  of  all  means  the  surest  to  produce  the  spoiled  child.  They 
should  never  appeal  to  the  child's  emotions,  by  showing  grief,  or  by 
using  the  "this  hurts  me  more  than  you"  argument.  Many  parents 
beHeve  they  can  disciphne  their  children  by  appeaHng  to  their  reason, 
and  by  affection  alone.  This  can  not  be  done;  the  child's  intellect 
is  not  sufficiently  developed  to  grasp  the  reasoning,  but  he  assents, 
and  promises,  and  learns  to  bribe  his  mother  to  overlook  naughtiness 
by  showing  her  excessive  affection  at  times. 

The  neglect  of  the  measures  of  training  and  discipline  outHned 
above,  leads  to  the  development  of  the  "spoiled  child,"  which  is  a 
very  distinct  type.  He  is  usually  bright,  precocious,  sensitive,  with 
a  highly  developed  mentality;  he  is  very  affectionate  and  demonstra- 
tive toward  his  parents.  On  the  other  hand  he  is  very  naughty, 
given  to  tantrums,  and  violent  fits  of  anger.  He  refuses  to  eat 
what  is  given  him  or  to  do  what  he  is  told,  and  when  corrected,  tries 
to  frighten  his  mother  by  the  display  of  all  sorts  of  terrifying  symp- 
toms. His  parents  usually  beHeve  that  his  temperament  and  nerv- 
ous system  are  so  exceptional,  that  he  cannot  be  properly  discipHned 
without  damage  to  his  sensitive  organization.     As  a  matter  of  fact 


-  Hygiene  and  Care 


51 


he  has  almost  unconsciously  become  an  adept  in  managing  his  par- 
ents, and  getting  his  own  way. 

Moderate  cases  of  this  description  can  be  corrected,  if  the  parents 
will  adopt  a  proper  system  of  discipline  with  sufficient  firmness.  The 
physician  must  aid  them  by  assuring  them  that  the  symptoms  which 
the  child  shows  under  discipline  will  not  ruin  his  nervous  system. 
Severe  cases  can  only  be  cured  by  taking  the  child  temporarily  entirely 
away  from  his  parents,  and  putting  him  in  charge  of  a  trained  nurse. 

To  teach  children  good  manners,  nothing  more  is  required  than  that 
the  parents  should  use  toward  the  children,  and  in  the  family,  all  the 
conventional  politeness  which  they  would  use  if  strangers  were  present. 

THE  NURSERY. — This  room,  in  which  the  child  passes  so  much 
of  its  time,  should  always  be  adapted  to  fulfil  its  hygienic  needs. 
It  should  be  a  large  room,  situated  high  up,  on  the  second,  or  third 
floor.  It  should  have  a  sunny  exposure  and  large  windows  high 
enough  from  the  floor  to  prevent  the  younger  children  continually 
pressing  their  faces  against  the  glass  to  look  out,  and  thus  catching 
cold  from  the  little  currents  of  air  which  penetrate  most  window 
casings.  Painted  walls  are  better  than  papered,  and  a  hard  wood 
floor  not  highly  polished,  with  a  large  rug  is  better  than  a  carpet. 
The  child  should  have  his  own  bed,  made  of  iron,  and  painted,  with 

Fig.  13 


Infant's  bed,  Infants'  Hospital 


52  The  Normal  Child 

sides  high  enough  to  prevent  him  from  falling  out  easily.  The 
pillow  and  mattress  should  be  of  felt,  folded  so  as  to  be  soft  and  com- 
fortable, and  pillow  and  mattress  cases  should  be  used.  The  mat- 
tress should  be  protected  by  a  rubber  sheet.  The  nurse's  bed  should 
not  be  too  close.  The  child  should  have  its  own  closet,  and  its  own 
bureau-drawers;  the  nurse's  belongings  should  be  kept  in  a  separate 
room.  The  furniture  should  be  simple,  not  complicated  or  cum- 
bersome; stuffed  furniture  should  be  avoided.  The  windows  should 
have  both  light  and  dark  shades,  and  only  simple  musHn  curtains. 
Toys  made  of  woollen  material  or  feathers,  or  which  have  colors 
which  can  be  soaked  off  by  saliva,  should  not  be  allowed. 

Steam  heat  is  not  desirable  in  the  nursery.  The  best  means  of 
heat  is  an  open  wood  fire,  and  the  next  best  a  coal  grate.  The  open 
fireplace  is  a  great  help  in  securing  good  ventilation.  The  window 
board  is  useful  in  securing  fresh  air,  but  if  the  room  is  always  thor- 
oughly aired  when  the  child  is  out,  the  window  need  not  be  open 
when  the  child  is  playing,  if  an  open  fire  is  burning.  The  tempera- 
ture of  the  nursery  should  not  be  above  70°  F.  when  the  child  is 
playing,  and  should  be  lower  when  the  child  is  sleeping. 

If  possible,  a  bathroom  should  immediately  adjoin  the  nursery. 
This  can  also  be  used  as  a  room  for  changing  the  diapers,  and  can 
be  kept  warm  enough  at  night  for  this  purpose,  when  the  nursery 
is  cold.  The  diapers  should,  if  possible,  never  be  changed,  washed, 
or  dried,  in  the  nursery. 

NURSERY-]MAIDS.— The  first  essential  of  the  attendant  who 
cares  for  the  young  child  is  health.  She  should  be  free  from  any 
suspicion  of  tuberculosis  or  sj'philis,  and  from  any  catarrhal  affections 
of  the  mucous  membranes.  The  idea  that  the  child  should  be 
taken  care  of  by  an  old,  experienced  nurse  is  a  vicious  one.  The 
experience  of  nurses,  as  a  rule,  is  that  of  ignorance  rather  than  of 
intelligence.  Every  mother,  as  she  is  presumably  more  intelligent 
than  the  nurse  whom  she  employs,  and  is  surely  more  interested  in 
the  welfare  of  her  child,  should  personally  supervise  and  unhesitat- 
ingly investigate  all  that  the  nurse  does  to  the  child.  The  nurse's 
ideas  as  to  what  is  needed  for  the  child's  hygienic  surroundings,  food, 
and  clothing  can  well  be  dispensed  with.  The  mother,  learning  from 
the  physician  what  is  best  for  her  child,  should  give  her  directions  to 
the  nurse  and'  see  that  these  directions  are  strictly  carried  out.  A 
nurse  between  the  ages  of  twenty  and  thirty-five  is  preferable  to  one 
who  is  younger  or  older.  She  should  be  neat,  healthy,  strong,  cheer- 
ful, gentle,  and  patient.  She  should  be  willing  to  refer  small  details 
of  the  nursery  routine  to  the  mother,  as  well  as  those  which  appear 
of  greater  importance.  The  chief  attributes  of  a  good  child's  nurse, 
in  my  opinion,  are  a  desire  to  obey  implicitly  the  orders  which  she 


Hygiene  and  Care  53 

receives  from  her  mistress,  and  a  temperament  in  harmony  with  the 
sensitive  nervous  organization  of  her  charge.  In  certain  cities,  such 
as  New  York,  Philadelphia,  Buffalo,  and  Boston,  schools  have  been 
estabHshed  for  nursery-maids,  where  the  nurses  are  trained  to  be 
servants  as  well  as  nurses. 

PREVENTION  OF  EXPOSURE  TO   CONTAGION.— Infants 

and  children  are  usually  guarded  from  exposure  to  such  well-known 
contagious  diseases  as  scarlet  fever  and  diphtheria,  but  no  precau- 
tions are  taken  against  exposure  to  such  conditions  as  the  common 
cold,  influenza  and  bronchitis,  all  of  which  are  contagious.  Members 
of  a  household  who  have  any  of  these  respiratory  affections  should 
be  quarantined  as  far  as  the  children  are  concerned.  Some  parents 
believe  that  children  should  not  be  guarded  from  such  contagious 
diseases  as  measles  and  whooping  cough,  on  the  ground  that  they  must 
have  them  at  some  time.  This  is  not  necessarily  true,  and  children 
should  always  be  guarded  against  exposure  to  these  diseases. 

Whenever  children  assemble  in  crowds,  especially  indoors,  the 
chances  of  contagion  are  much  increased.  The  moving  picture  shows 
have  become  very  fruitful  sources  of  contagion,  and  young  children 
should  not  be  taken  to  them. 

SUMMER  RESORTS.— The  physician  is  frequently  consulted 
as  to  where  the  child  is  to  be  taken  for  the  summer.  In  my  experi- 
ence, chiefly  gained  among  children  who  pass  the  winter  near  the 
sea,  our  inland  mountain  summer  resorts  are  far  preferable  to  the 
sea-shore.  Children  may  advantageously  pass  part  of  the  summer  in 
the  mountains  or  inland,  and  part  by  the  sea.  A  whole  summer  at 
the  sea-shore  should  be  avoided.  It  is  probable  that  with  children 
who  live  inland  in  winter,  the  sea-shore  resorts  in  summer  would  not 
be  open  to  objection. 

THE  DAILY  ROUTINE  OF  THE  NORMAL  CHILD.— I  have 
devoted  considerable  space  to  the  hygiene  and  care  of  the  normal 
child.  It  has  come  to  be  recognized  that  Preventive  Medicine  is 
one  of  the  most  important,  if  not  the  most  important,  branch  of  the 
art  of  medicine.  It  is  especially  important  in  early  life,  where  a 
very  large  proportion  of  the  pathological  conditions  which  develop 
ma}^  be  traced  to  some  violation  of,  or  lack  of  attention  to,  the  small 
details  of  hygiene  and  care  required  by  the  undeveloped  condition 
of  the  young  human  being.  The  modern  mother  understands  the 
importance  of  all  the  little  details  of  care  in  regulating  the  environ- 
ment of  the  child,  and  it  is  on  these  points  mostly  that  she  consults 
the  specialist  in  pediatrics.  She  no  longer  looks  to  the  physician 
as  a  writer  of  prescriptions  when  the  children  are  ill,  but  as  the 
expert  adviser  to  whom  she  can  go  when  she  wants  to  know  how 
to  bring  up  the  child  in  such  a  way  that  illness  is  prevented.     The 


54 


The  Normal  Child 


physician  must  be  familiar  with  every  detail  of  the  child's  daily  hfe, 
and  much  of  his  work  is  the  careful  regulation  of  every  detail  of  the 
child's  environment. 

This  arranging  of  the  daily  routine  is  sometimes  very  diflficult. 
It  seems  hard  to  make  everything  fit  in  right  in  the  course  of  the 
day;  meals  conflict  with  outdoor  airings,  and  naps  with  exercise. 
Many  things  have  to  be  taken  into  consideration,  such  as  the  nurse's 
dinner,  and  other  ways  of  the  household  difficult  to  change.  As  a 
guide  in  arranging  the  daily  routine  to  meet  the  needs  at  various 
ages  for  food,  sleep,  and  exercise,  the  following  time  table  is  sub- 
mitted. It  is  intended  to  serve,  not  as  an  arbitrary  rule,  but  simply 
as  a  model,  to  be  modified  according  to  circumstances. 


Table  ii 
Time  Table  for  the  Daily  Routine  in  Infancy  and  Early  Childhood 


FIRST  6  ■WEEKS 

6:00  A.M Feeding 

7:30  A.M Morning  Toilet 

8  :oo  A.M Feeding 

10:00  A.M Feeding 

10:30  A.M.  to  12:00  M. Outdoors 

1 2  :oo  M Feeding 

2  :oo  P.M Feeding 

2:30  to  4:00  P.M Outdoors 

4:00  P.M Feeding 

5:30  P.M.. Bath 

6  :oo  P.M Feeding 

10:00  P.M Feeding 

2:00  A.M Feeding 


5  TO  12  MONTHS 

6  :oo  A.M Feeding 

7 :30  A.M Morning  Toilet 

q:oo  A.M Feeding 

10:00  A.M.  to  12:00  M. Outdoors — Nap 

1 2  :oo  M Feeding 

1:00  to  3:00  P.M Outdoors — Nap 

3  :oo  P.M Feeding 

3:30  to  5:30  P.M Play 

5:30  P.M Bath 

6:00  P.M Feeding  and  Bed 


18  TO  24  MONTHS 

7  :oo  A.M Feeding 

8:00  A.M ; Sponge  Bath 

9:00  A.M Orange  Juice 

10:00  to  11:00  A.M.  .  .  .Outdoors 

II  :oo  A.M Feeding 

11:30  A.M.  to 

12:30  P.M Outdoors 

12:30  to  2:30  P.M Nap 

2:30  P.M Feeding 

.3:00  to  4:00  P.M Outdoors 

5:30  P.M Bath 

6:00  P.M Feeding  and  Bed 


6  \^^EEKS  TO  5  MONTHS 

6:00  A.M * Feeding 

7 :3o  A.M Morning  Toilet 

8:30  A.M Feeding 

10:00  to  11:00  A.M. . .  .Outdoors 

1 1  :oo  A.M Feeding 

11:30  A.M.  to 

12:30  P.M Outdoors 

1 :30  P.M Feeding 

2:00  to  4:00  P.M Outdoors 

4:00  P.M Feeding 

4:00  to  5:30  P.M Play 

6:00  P.M Bath 

6:30  P.M. .  .  .  •. Feeding 

9  :oo  P.M Feeding 

2  :oo  A.M Feeding 

12  TO  18  MONTHS 

7  :oo  A.M Feeding 

8:00  A.M Sponge  Bath 

9:00  A.M Orange  Juice 

10:00  to  11:00  A.M.  . .  .Outdoors 

1 1  :oo  A.M Feeding 

11:30  A.M.  to 

12 :30  P.M Outdoors 

12:30  to  1:30  P.M Nap 

1 :30  to  3  :oo  P.M Outdoors 

3  :oo  P.M Feeding 

3:30  to  5:30  P.M Nap 

5:30  P.M Bath 

6:00  F.M Feeding  and  Bed 

2  TO  6  YEARS 

7:00  A.M Sponge  Bath 

7:30  A.M Breakfast 

10:00  to  12:00  A.M.  . .  .Outdoors 

1 2  :oo  M Dinner 

12:30  to  2:30  P.M Nap 

2:30  to  4:00  P.M Outdoors 

5:30  P.M Bath 

6  :oo  P.M Supper  and  Bed 


DIVISION  II 

DISEASE  IN  EARLY  LIFE 

L     ETIOLOGY  AND  CLASSIFICATION 

The  classification  of  diseased  conditions  has  always  presented 
almost  insuperable  difficulties  for  the  medical  writer.  In  earliest 
times  diseases  were  classified  upon  the  basis  of  their  symptoms,  or 
of  unscientific,  or  superstitious  theories  as  to  their  cause  and  nature. 
Later  the  spread  of  knowledge  concerning  pathological  anatomy 
suggested  a  purely  anatomical  basis  for  the  classification  of  disease. 
Such  a  basis,  however,  has  proved  unsatisfactory  for  many  reasons, 
chief  among  which  being  the  fact  that  many  conditions  recognizable 
as  diseases  present  no  distinctive  anatomical  features,  and  the  fact 
that  the  lesions  of  disease  bear  no  definite  relation  to  the  cause, 
symptoms  or  method  of  cure.  If  there  were  such  a  relation,  classi- 
fication would  be  a  simple  matter.  In  its  absence,  attention  has 
been  turned  more  and  more  toward  etiologic  factors  as  the  most 
important  conditions  differentiating  diseased  processes  from  one 
another,  especially  since  progress  in  bacteriology  has  set  apart  a, 
large  class  of  diseases  as  having  a  demonstrable  specific  cause.  Treat- 
ment, also,  is  becoming  more  and  more  directed  at  the  causes,  rather 
than  at  the  lesions  of  disease,  and  this  suggests  how  advantageous 
would  be  an  etiologic  basis  of  classification,  if  it  were  possible. 

Unfortunately,  it  is  as  yet  impossible  to  classify  diseased  condi- 
tions solely  upon  the  basis  of  their  etiology,  for  two  principal  rea- 
sons. In  the  first  place,  there  is  no  subject  in  the  scientific  aspect 
of  medicine  more  obscure  than  that  of  etiology.  The  etiology  of 
many  recognizable  diseased  conditions  remains  wholly  unknown.  In 
the  second  place,  a  great  many  diseased  conditions  which  can  be 
recognized  as  fairly  distinct  disturbances,  are  produced  by  the  coin- 
cident action  of  a  number  of  different  etiological  factors.  More- 
over, the  same  etiologic  factor  may,  at  different  times,  produce 
wholly  different  lesions,  or  disturbances  of  bodily  function,  the  prob- 
able explanation  of  this  phenomenon  being  that  there  are  other 
coexisting  causes  which  cannot  be  recognized. 

Nevertheless,  etiology  must  not  be  discarded  in  any  attempt  to 
classify  disease,  but  should  be  used  as  far  as  is  possible,  the  defici- 
ency in  our  knowledge  being  eked  out  by  what  we  know  of  the  essen- 
tial manner  in  which  various  diseased  processes  are  produced.     We 


56  Disease  in  Early  Life 

know,  for  instance,  that  in  some  cases  the  result  of  the  action  of 
a  cause  or  group  of  causes  is  a  definite  anatomic  lesion;  in  other 
cases  the  result  is  a  disturbance  of  the  function  of  a  particular  organ; 
in  still  other  cases  a  disturbance  of  the  entire  nutrition  and  meta- 
bolism, with  or  without  the  formation  of  toxic  substances  in  the 
blood. 

By  taking  account  both  of  causes,  and  the  various  kinds  of  dis- 
turbances produced  in  the  body,  a  basis  for  the  classification  of 
disease  may  be  constructed  which  will  be  sufficiently  useful  to  meet 
the  requirements  of  the  present  stage  of  our  knowledge. 

THE  CAUSES  OF  DISEASE 

The  following  are  the  chief  etiological  factors  in  disease: 

1.  Inheritance. 

2.  The  normal  lack  of  development  of  early  life. 

3.  Unknown  internal  causes. 

4.  Mechanical  injury  from  without. 

5.  External  factors  in  hygiene  and  environment. 

6.  Infection. 

Of  these  causes,  the  first  three  represent  conditions  existing  within 
the  body  of  the  child.  The  last  three  represent  conditions  of  en- 
vironment, acting  upon  the  child's  body  from  without. 

INHERITANCE  is  an  important,  though  rather  obscure  factor. 
Syphihs  is  the  only  disease  often  directly  transmitted  from  parent 
to  child,  though  there  are  rare  instances  of  the  transmission  of  other 
infections.  Inheritance  plays  its  chief  part  in  the  transmission  of 
what  are  commonly  called  constitutional  weaknesses  or  tendencies. 
If,  as  is  probable,  there  is  an  anatomical  basis  for  these  tendencies, 
it  is  not  recognizable.  Lack  of  resistance  to  other  causes  of  disease 
is  all  we  can  see,  the  children  being  liable  to  certain  infections,  or 
to  certain  disturbances  of  function. 

THE  NORMAL  LACK  OF  DEVELOPMENT  OF  EARLY  LIFE 

has  been  thoroughly  described  in  the  first  division  of  this  book.  In 
itself  alone,  it  can  not  properly  be  called  a  cause  of  disease.  It  is, 
however,  a  very  important,  if  not  the  most  important,  etiological 
factor  in  connection  with  other  causes  acting  from  without.  It 
explains  why  children  are  less  resistant  to  certain  conditions  of  their 
environment. 

UNKNOWN  INTERNAL  CAUSES.— There  are  certain  disturb- 
ances which  occur  only  at  times,  and  which  cannot  be  traced  to 
inheritance,  or  to  any  external  cause.  The  cause  may  be  external, 
but  if  so,  it  has  not  been  discovered.  Unknown  internal  causes  are 
included  only  as  a  possible  explanation  of  these  conditions. 


Etiology  and  Classification  57 

MECHANICAL  INJURY  FROM  WITHOUT  needs  no  explana- 
tion. The  effects  of  blows,  of  falls,  of  birth  injuries,  of  foreign 
bodies  in  internal  structures,  of  heat,  of  cold,  of  irritants,  are  well 
known. 

THE  EXTERNAL  CONDITIONS  IN  THE  HYGIENE  AND 
ENVIRONMENT  OF  THE  CHILD  which  can  produce  disease  are, 
of  aH  etiologic  factors,  the  most  numerous  and  important.  Among 
them  may  be  numbered  improper  feeding,  unhygienic  surroundings, 
neglect,  and  indeed  any  violation  of  the  rules  for  the  proper  care 
of  the  child. 

INFECTION  means  the  invasion  of  the  body  from  without  by 
a  living  pathogenic  parasite.  The  mode  of  action  of  these  micro- 
organisms and  the  mechanism  of  defense  against  them,  will  be  de- 
scribed in  other  portions  of  this  book. 

HOW  THE  VARIOUS  CAUSES  ACT  IN  PRODUCING 

DISEASE 

There  are  three  principal  ways  in  which  the  various  known  and 
unknown  causes  of  disease  act  in  the  body. 

1.  By  producing  faulty  anatomical   development  in  intraute- 

rine life. 

2.  By  producing  disturbance  of  function  without  primary  anat^ 

omic  lesions. 
.3.  By  producing  primary  anatomic  lesions. 

CONGENITAL  FAULTS  OF  DEVELOPMENT.— In  the  first 
group  the  causes  are  entirely  unknown.  They  may  be  inherited 
tendencies,  or  internal  unknown  causes,  or  external  conditions  acting 
on  the  foetus  through  the  mother.  This  subject  is  still  shrouded 
in  mystery.  Our  knowledge  of  embryology  tells  us  only  just  what 
phase  of  development  goes  wrong  in  embryonic  life. 

DISTURBANCE  OF  FUNCTION  WITHOUT  EVIDENT  PRI- 
MARY ANATOMIC  LESION.— This  is  very  common.  Such 
disturbance  is  usually  due  to  the  coincident  operation  of  several 
causes.  Normal  lack  of  development  plus  inherited  weakness,  for 
example,  unite  with  faulty  hygiene  in  producing  a  disturbance  of 
function.  All  sorts  of  combinations  and  successions  of  events  may 
exist.  Thus  the  faulty  hygienic  surroundings  of  the  mother  may 
cause  congenital  lack  of  resistance  on  the  part  of  the  child,  which 
permits  disturbance  of  function  under  conditions  which  are  normal 
and  not  injurious  to  normal  babies.  In  most  cases  of  disturbed 
function,  multiple  causes,  involving  both  internal  and  external  fac- 


58  Disease  in  Early  Life 

tors  must  be  sought.  Lack  of  balance  between  the  child's  func- 
tional development  and  the  conditions  of  his  environment  is  the 
usual  finding. 

The  functions  disturbed  are  various.  A  single  organ,  or  several 
organs  may  be  involved.  There  may  be  a  disturbance  of  the  entire 
function  of  nutrition  and  metabolism.  The  results  of  the  disturb- 
ance are  very  manifold,  showing  a  great  variety  of  manifestations. 
For  example,  disturbance  of  nutrition  and  metabolism  may  give  rise 
simply  to  retardation  of  growth  and  development,  or  to  distinct 
diseases  such  as  rachitis  and  scorbutus,  or  to  toxemias. 

Toxemias. — One  manifestation  of  disturbed  function  is  so  very 
striking,  and  has  attracted  so  much  attention  recently,  that  it  de- 
serves special  mention,  if  not  a  special  place  in  the  general  classifica- 
tion of  disease.  I  refer  to  toxemia.  There  exist  a  number  of 
clinical  manifestations,  some  of  which  can  be  proved  to  be  due  to 
the  formation  of  toxic  substances  and  their  circulation  in  the  blood, 
and  others  which  can  be  best  explained  on  this  basis  even  without 
proof.  These  toxemias  would  hold  a  place  in  the  classification  of 
disease,  were  it  not  for  the  fact  that  we  believe  them  to  be  manifes- 
tations of  disturbed  function,  either  of  an  organ,  or  more  commonly, 
of  the  whole  metaboHsm.  These  toxic  substances  may  in  turn  cause 
secondary  disturbances  of  function,  which  brings  them  into  the  class 
of  etiological  factors.  They  may  even  produce  lesions,  such  as  are 
seen  in  the  kidneys  in  some  forms  of  nephritis,  or  in  the  bones  in 
rhachitis  and  scorbutus.  Their  mode  of  action  is  often  not  very 
different  from  conditions  seen  in  infections,  where  there  is  also  a 
toxemia,  the  only  difference  being  that  the  toxins  are  of  bacterial 
and  not  of  metaboHc  origin. 

In  this  group  of  functional  disturbances  are  included  all  condi- 
tions in  which  disturbance  of  function,  and  not  a  lesion,  is  the  pri- 
mary result  of  the  various  etiologic  factors.  Lesions,  however,  may 
often  be  seen  in  these  conditions.  For  example,  improper  feeding 
may  cause  disturbance  of  the  function  of  digestion,  which  in  turn 
causes  irritation  of  the  intestinal  mucosa,  which  in  its  turn  eventually 
may  give  rise  to  an  intestinal  lesion. 

PRIMARY  ANATOMIC  LESIONS.— This  is  a  very  important 
manner  in  which  the  etiological  factors  produce  disease.  It  requires 
little  discussion,  as  this  origin  of  disease  is  thoroughly  understood. 
The  two  chief  etiologic  factors  concerned  here  are  mechanical  injury 
from  without,  and  infection.  The  former  produces  the  various  forms 
of  lesion  grouped  under  the  general  term  of  traumatic.  The  second 
produces  a  great  variety  of  lesions  peculiar  to  the  particular  form 
of  infection  involved.  There  is  a  class  of  lesions  of  unknown  cause, 
represented  by  the  new  growths. 


Etiology  and  Classification  59 

THE  CLASSIFICATION  OF  DISEASE 

Using  as  a  basis  both  what  we  know  of  etiology,  and  what  we 
know  of  the  mode  of  action  of  various  causes,  the  following  classi- 
fication of  diseases  is  suggested,  and  will  be  followed  in  this  book: 

1.  Malformations. 

2.  Mechanical  injuries — 

a.  From  external  causes — trauma. 

b.  From  unknown  internal  causes. 

3.  New  growths.  * 

4.  Functional  disturbances  from  multiple  causes — 

a.  Non-toxic. 

b.  Toxemias. 

5.  Infections. 

THE  MALFORMATIONS  represent  the  faulty  intrauterine  de- 
velopment described  above,  of  which  the  cause  is  unknown.  It 
includes  all  the  congenital  malformations. 

THE  MECHANICAL  INJURIES  from  trauma  need  no  expla- 
nation. Those  from  unknown  internal  causes  are  represented  by 
such  conditions  as  hernia  and  intussusception. 

THE  NEW  GROWTHS  represent  very  distinct  and  pecuhar 
lesions,  of  which  the  cause  is  still  unknown.  W^hether  the  origin 
of  these  lesions  is  developmental,  or  whether  it  is  to  be  found  in 
some  as  yet  undiscovered  agency  acting  from  without,  is  for  the 
future  to  determine.  For  the  present  these  lesions  can  only  occupy 
a  class  by  themselves. 

THE  FUNCTIONAL  DISTURBANCES  trace  their  position  as 
a  separate  class  of  diseases  to  the  essential  nature  of  the  disease 
process,  rather  than  to  the  nature  of  the  causes,  which  are  multiple. 
The  essential  feature  is  disturbance  of  function  without  primary 
anatomic  lesions.  Those  disturbances  in  which  the  manifestations 
are  chiefly  chemical,  caused  by  the  formation  of  toxic  substances  and 
their  circulation  in  the  blood,  are  grouped  under  the  subdivision  of 
toxemias.  Examples  of  non-toxic  functional  disturbances  are  indi- 
gestion from  overfeeding,  and  enuresis;  of  toxic  functional  disturb- 
ances are  spasmophilia,  and  some  forms  of  nephritis. 

THE  INFECTIONS  form  the  most  distinct  group  etiologically. 


II.     PATHOLOGICAL  ANATOMY 

The  peculiarities  of  the  pathology  of  early  life  lie  in  the  relative 
frequency  of  the  different  processes  rather  than  in  any  marked  modi- 
fication of  their  character.  The  tissue  changes  which  form  the 
lesions  of  disease  are  the  same  at  all  ages.  In  childhood,  however, 
the  relative  frequency  of  different  kinds  of  lesions  is  dift'erent  from 
that  seen  in  adult  hfe,  and  there  are  more  or  less  characteristic  modi- 
fications in  the  severity  and  distribution  of  the  lesions.  The  varia- 
tions characteristic  of  the  pathology  of  early  life  are  most  notable 
in  infancy,  and  become  progressively  less  through  childhood,  until, 
at  about  the  age  of  puberty,  adult  conditions  are  reached. 

Congenital  lesions  form  a  comparatively  large  group  in  the  path- 
ological anatomy  of  early  life,  particularly  in  infancy.  They  may 
be  subdi\'ided  upon  an  etiological  basis  into  two  classes,  one  being 
due  to  embryonic  conditions  —  abnormahties  of  fetal  development, 
the  other  being  due  to  intrauterine  disease.  Closely  connected  with 
these  congenital  lesions  is  another  group  due  to  trauma  sustained 
during  birth. 

Functional  disturbances,  without  recognizable  primary  lesions,  are 
comparatively  common  in  early  Hfe.  The  multiple  etiology  of  these 
conditions  has  been  discussed  in  the  section  on  etiolog}-.  In  early 
hfe,  disturbance  of  function  is  most  common  in  those  organs  or.  sys- 
tems of  the  body  which  in  childhood  show  a  relative  backwardness 
of  functional  development.  Consequently,  functional  disturbances 
in  early  hfe  are  most  commonly  connected  with  the  digestive  system 
and  nutrition,  and  with  the  nervous  system.  The  largest  divisions  of 
any  work  on  pediatrics  must  be  those  dealing  with  nutrition,  meta- 
boHsm,  and  the  gastro-enteric  tract.  The  circulatory  system  in 
early  life  is  comparatively  well-developed,  while  it  contains  the  tis- 
sues and  organs  which,  having  a  mechanical  function,  show  most 
markedly  the  effects  of  the  strain  of  advancing  years,  and  of  active 
abuses.  Consequently,  functional  disturbances  of  the  heart  and 
circulation  are  comparatively  uncommon  in  childhood. 

New  growths  are  very  much  less  common  in  childhood  than  in 
adult  life.  Carcinoma,  the  most  common  tumor  of  later  Hfe,  is 
almost  unknown  in  infancy  and  childhood.  Full  development  and 
maturity  appears  to  be  an  essential  condition  for  the  occurrence  of 
many  varieties  of  new  growth.  Thus  the  fibro-myomata  of  the  uterus, 
and  the  cysts  of  the  ovary,  so  common  in  adult  life,  are  not  seen  in 
childhood.     Sarcoma  is  the  most  common  new  growth  encountered 


Pathological  Anatomy  61 

in  childhood,  the  commonest  form  being  osteo-sarcoma,  and  sarcoma 
of  the  kidney  originating  in  adrenal  tissue.  Gliomata  also  are 
often  seen. 

The  inflammatory  lesions  characteristic  of  infection  are  compara- 
tively common  in  early  life,  and  form  by  far  the  largest  group  in 
the  pathological  anatomy  of  infancy  and  childhood.  The  great 
liability  of  children  to  the  group  of  infectious  diseases  transmitted 
by  contact,  has  led  to  the  name  of  "children's  diseases"  being  applied 
to  this  group.  The  frequency  of  the  contagious  diseases  in  child- 
hood is,  however,  probably  not  chiefly  due  to  an  increased  suscepti- 
bility at  that  period  of  life.  Indeed,  infants  as  compared  with  older 
children  show  a  distinct  immunity  to  certain  contagious  diseases, 
such  as  dipthheria  and  scarlet  fever,  which  may  be  possibly  explained 
by  a  partial  transmission  of  immunity  from  the  mother.  The  rela- 
tive frequency  of  the  contagious  infections  in  childhood  is  to  be 
explained  chiefly  by  the  fact  that  these  diseases  confer  an  immunity 
upon  the  patient,  and  are  not  seen  in  adult  life  because  of  the  im- 
munity acquired  in  childhood.  The  problem  of  susceptibility  and 
immunity  is,  however,  very  complex,  and  undoubtedly  there  exists 
in  the  undeveloped  tissues  of  the  growing  child  an  increased  sus- 
ceptibility toward  certain  infections. 

The  mucous  membrane  of  the  respiratory  tract  is  particularly 
liable  to  infection  in  early  life,  and  the  inflammatory  lesions  caused 
by  infection  are  the  commonest  found  at  autopsies  on  children. 
Pneumonia  is  very  common,  and  the  lungs  are  rarely  found  normal 
at  autopsy  after  an  acute  infectious  disease  of  long  duration.  The 
great  frequency  of  acute  inflammation  of  the  middle  ear  is  also  a 
very  notable  feature  in  the  pathology  of  infancy  and  early  childhood. 
The  nose,  throat,  and  larynx  show  about  the  same  susceptibility  to 
catarrhal  inflammation  as  in  the  adult.  The  mouth,  however^  is 
peculiarly  liable  to  lesions  in  childhood,  both  of  infectious  and  of 
traumatic  origin. 

There  is  a  marked  difference  between  childhood  and  adult  life 
in  the  character  of  the  lesions  found  in  the  heart.  In  infants,  prac- 
tically the  only  lesions  found  are  of  congenital  origin.  In  older 
children,  the  heart,  both  endocardium  and  pericardium,  are  partic- 
ularly liable  to  the  inflammatory  lesions  characteristic  of  acute  in- 
fection. The  lesions  due  to  chronic  endocarditis  and  its  mechan- 
ical effects,  are  less  common  than  in  adult  life.  At  autopsy,  acute 
endocarditis  or  pericarditis  is  the  usual  finding  in  cardiac  cases. 

Arteriosclerosis,  and  the  whole  group  of  lesions  secondary  to  vascu- 
lar changes,  which  are  found  in  all  the  organs  of  the  body,  and  which 
play  so  important  a  part  in  the  pathology  of  adult  life,  are  almost 
unknown  in  childhood.     Such  conditions  are  angina  pectoris,  chronic 


62  Disease  in  Early  Life 

myocarditis,  "  cardio-renal  cases,"  chronic  interstitial  nephritis,  hemor- 
rhage into  the  internal  capsule  of  the  brain,  and  so  forth,  play  little 
or  no  part  in  the  pathology  of  childhood. 

The  nervous  system  in  childhood  presents  a  widely  different  path- 
ology from  that  of  adult  life.  These  differences  may  be  summarized 
as  follows:  i.  The  greater  frequency  of  congenital  lesions.  2.  The 
greater  frequency  of  some  forms  of  functional  disturbance  (chorea, 
epilepsy,  pavor  nocturnus)  and  the  lesser  frequency  of  others  (hys- 
teria). 3.  The  lesser  frequency  of  processes  showing  the  pathological 
anatomy  of  chronic  degeneration.  4.  The  greater  frequency  of  acute 
infections.  In  connection  with  the  last  two  points,  it  is  notable  that 
such  nervous  diseases  as  tabes  dorsalis,  syringo-myelia,  paralysis 
agitans,  and  similar  conditions  are  very  uncommon  in  childhood. 
On  the  other  hand,  both  meningitis  in  all  its  forms,  and  poHomyelo- 
encephalitis  are  much  more  common  in  children  than  in  adults. 

Lesions  of  the  lymph  nodes  play  an  important  part  in  the  path- 
ological anatomy  of  early  Hfe.  They  are  affected  secondarily  to  the 
various  inflammations  of  the  mucous  membranes,  and  the  result  of 
acute  infection  is  the  suppurative  inflammation  so  common  in  infants, 
while  prolonged  chronic  infection  causes  a  condition  of  chronic  lymph 
node  hyperplasia.  The  same  condition  of  chronic  hyperplasia  is  also 
a  very  common  secondary  lesion  in  the  various  chronic  nutritional 
disturbances.  The  thymus  plays  a  part  in  the  pathology  of  infancy 
only. 

The  serous  membranes  are  less  often  the  seat  of  lesions  in  child- 
hood than  in  adult  life.  Empyema  is  rather  commoner,  as  is  tuber- 
culous peritonitis,  but  the  other  forms  of  pleurisy  and  peritonitis 
are  less  often  seen. 

The  skin  in  early  Hfe  is  very  delicate.  Consequently  it  is  very 
often  the  seat  of  lesions  caused  by  infection,  or  by  mechanical  irri- 
tation. The  group  of  lesions  seen  in  adults  which  represent  degen- 
erative conditions,  the  results  of  wear  and  tear,  are  not  seen  in 
childhood. 

Certain  diseases,  chiefly  infectious,  which  occur  both  in  childhood 
and  in  adult  life,  present  peculiarities  in  pathological  anatomy  char- 
acteristic of  childhood.  Notable  among  these  diseases  are  tuber- 
culosis, syphiHs,  typhoid  fever,  and  rheumatic  fever.  The  lesions 
characteristic  of  childhood,  and  the  variations  in  the  pathological 
anatomy  from  that  of  adults,  will  be  described  in  detail  in  connec- 
tion with  the  conditions  in  which  they  occur. 


III.     SYMPTOMATOLOGY  AND  DIAGNOSIS 

THE  HISTORY 

The  first  step  in  the  diagnosis  and  treatment  of  a  diseased  con- 
dition is  the  obtaining  of  the  history.  Here  at  once  are  encountered 
conditions  fundamentally  different  from  those  met  with  in  dealing 
with  disease  in  adults.  A  child  cannot  give  a  description  of  its 
symptoms,  and  consequently  the  history  must  be  obtained  from  a 
parent,  nurse,  or  other  attendant.  This  is  particularly  the  case  with 
very  young  children,  who  are  not  able  to  describe  any  symptoms 
nor  to  answer  any  questions,  and  with  children  in  the  first  years  of 
life,  the  entire  history  of  the  case  must  be  obtained  from  the  parent. 
Older  children  are  able  to  tell  their  stories,  and  describe  their  symp- 
toms, but  their  powers  of  description  are  often  very  deficient,  and 
their  statements  very  misleading.  Even  in  older  children,  the  main 
source  of  information  is  the  story  of  the  parent,  corroborated  and 
assisted  by  what  the  children  are  able  to  tell.  For  this  reason, 
subjective  symptoms  play  a  comparatively  small  part  in  the  symp- 
tomatology of  infancy  and  early  childhood,  and  such  as  can  be  ob- 
tained have  to  be  accepted  at  second  hand.  As  far  as  the  history 
is  concerned,  particularly  in  young  children,  the  physician  is  com- 
pelled to  rely  on  the  objective  symptoms  as  observed  and  reported 
by  another  person,  usually  the  mother,  whose  powers  of  observation 
and  description  are  not  trained,  and  are  often  very  inadequate.  This 
tends  to  diminish  the  importance  of  this  history  in  early  life.  It 
must  not  be  assumed,  however,  that  the  history  is  not  important. 
The  physician  must  understand  the  conditions  under  which  it  is 
obtained,  and  the  comparative  degree  of  importance  to  be  attached 
to  the  various  symptoms  reported. 

It  is  often  supposed  by  the  laity,  and  even  by  physicians  who  are 
not  trained  in  the  diagnosis  of  disease  in  early  life,  that  this  diffi- 
culty in  obtaining  a  history  constitutes  one  of  the  chief  difficulties 
in  pediatric  practice.  It  is  often  said  that  practice  among  babies 
must  be  especially  difficult  "  because  they  cannot  tell  how  they 
feel."  It  is  not  true  that  this  constitutes  an  especial  difficulty,  but 
it  is  rather  that  it  constitutes  a  need  for  special  training.  The 
pediatrist  must  become  especially  practiced  in  the  observation  and 
interpretation  of  objective  symptoms.  Moreover,  the  inability  of 
the  patient  to  tell  "how  he  feels"  presents  a  distinct  advantage 
from  certain  points  of  view.  The  long  accounts  of  feelings  pre- 
sented by  sick  adults,  often  exaggerated  by  the  results  of  prolonged 


64  Disease  in  Early  Life 

auto-suggestion  which  may  even  amount  to  hypochondriasis,  are  not 
of  much  value  in  diagnosis,  and  are  often  actively  misleading.  In 
children,  the  clinical  picture  is  often  all  the  more  clear-cut,  from  the 
absence  of  subjective  symptoms. 

In  obtaining  the  history  it  is  well  to  let  the  mother  tell  the  story 
first  without  cross-examination.  When  the  story  is  complete,  the 
physician  should  begin  his  questioning,  not  with  the  family  history 
or  previous  history,  but  with  the  present  illness.  It  is  very  dis- 
concerting to  a  mother,  whose  mind  is  earnestly  bent  on  describing 
clearly  the  illness  of  the  child,  and  who  has  just  completed  her  story, 
to  be  immediately  asked  what  her  other  children  died  of,  and  whether 
there  is  tuberculosis  in  the  family.  Such  questions  give  the  im- 
pression that  the  physician  is  merely  proceeding  by  rote,  that  he  is 
not  interested  in  her  story,  nor  in  the  real  trouble  with  the  child, 
and  they  tend  to  trouble  and  confuse  her.  The  physician  should  begin 
by  asking  questions  on  the  various  points  mentioned  in  the  mother's 
story,  with  a  view  to  bringing  out  and  defining  the  various  symp- 
toms. He  should  then  ask  the  questions  necessary  for  the  completion 
of  the  history  of  the  present  illness.  The  family  and  previous  his- 
tory can  just  as  well  be  obtained  after  the  story  of  the  present  iliiness 
is  complete. 

SIGNIFICANCE    OF    SYMPTOMS    IN    EARLY    LIFE.     In 

children,  as  compared  with  adults,  subjective  symptoms  are  less 
marked,  while  objective  symptoms  are  more  marked.  In  infants, 
the  symptoms  reported  by  the  mother  are  all  objective.  It  must 
be  remembered  that  there  is  often  an  unconscious  tendency  on  the 
part  of  the  mother  to  exaggerate  the  severity  of  the  objective  signs 
which  she  has  observed.  There  is  also  a  tendency  to  interpret  them 
wrongly,  and  to  call  things  by  misleading  names.  Such  symptoms 
as  loss  of  appetite,  loss  of  weight,  vomiting,  diarrhea,  cough,  con- 
vulsions, restlessness,  insomnia,  and  so  forth,  are  apt  to  be  somewhat 
exaggerated.  On  the  other  hand,  such  symptoms  as  dyspnoea, 
apathy,  clouding  of  the  mentality,  paralysis,  and  others,  are  apt  to 
be  insufficiently  noticed. 

In  older  children,  subjective  symptoms  occur.  There  is  often  an  un- 
conscious tendency  on  the  part  of  both  the  mother,  and  the  physician. 
to  underestimate  the  severity  and  importance  of  subjective  symptoms. 
Such  symptoms  are  not  so  varied,  nor  so  common  as  in  the  adult. 
Pain  is  a  much  less  common  symptom  in  childhood,  and  in  many 
diseased  conditions,  it  is  apparently  less  severe.  When,  however, 
subjective  symptoms  are  present,  they  are  very  important  in  children. 

THE  FAMILY  HISTORY.— In  the  majority  of  cases,  this  should 
begin  with  the  parents.  The  general  health  and  constitutional  vigor 
of  both  parents  should  be  ascertained.  The  diseased  conditions  having 


The  History  65 

most  bearing  on  the  child  are  tuberculosis,  rheumatism,  syphiHs  and 
alcoholism.  The  first  two  should  be  inquired  about  specifically.  In 
the  case  of  tuberculosis,  the  transmission  from  the  parent  usually 
depends  rather  upon  exposure  to  contagion  than  upon  transmission 
of  the  disease  directly,  or  of  a  hereditary  tendency  toward  the  disease. 
It  is  consequently  advisable  not  to  limit  the  inquiry  to  tuberculosis 
in  the  parents,  but  to  extend  it  in  such  a  way  as  to  ascertain  if  pos- 
sible, whether  the  child  has  ever  come  into  contact  with  a  tuber- 
culous individual.  Neurotic  tendencies  in  the  parents  should  also 
be  ascertained  when  present.  It  is  usually  unnecessary  to  ask  direct 
questions  as  to  syphilis  or  alcoholism,  unless  something  in  the  history 
of  the  present  illness,  or  in  the  physical  examination,  should  suggest 
the  -advisability  as  to  inquiries  along  these  lines.  The  number  of 
other  children  living,  and  their  general  health,  should  be  ascertained. 
The  number  of  dead  children,  and  the  cause  of  death,  should  also 
form  part  of  the  record.  Also,  in  connection  with  the  family  history, 
it  is  advisable  to  gain  as  thorough  as  possible  an  insight  into  all  the 
surroundings  of  the  patient.  It  is  particularly  important  to  find  out 
whether  there  has  been  any  recent  exposure  to  contagious  disease. 

PREVIOUS  HISTORY. — There  are  four  points  of  importance 
to  be  elicited  in  the  previous  history  of  the  patient.  These  are, 
(i)  the  circumstances  attending  birth,  (2)  the  feeding  history,  (3)  the 
history  of  development,  and  (4)  the  history  of  previous  illness. 

The  Birth. — The  physician  should  first  inquire  whether  the  child 
was  premature,  or  born  at  full  term.  The  character  of  the  labor 
should  be  inquired  into,  whether  natural,  instrumental,  unduly  pro- 
longed, or  attended  by  complications.  Inquiry  should  be  made  as 
to  whether  the  child  appeared  normal  at  birth,  whether  it  seemed 
vigorous,  whether  it  breathed  promptly,  and  whether  it  took  the 
breast  well.  The  nutrition  of  the  child  during  the  early  days  of  Hfe, 
and  the  existence  of  any  symptoms,  such  as  hemorrhage  or  convul- 
sions, should  be  ascertained. 

The  Feeding. — The  physician  should  next  ask  whether  the  child 
was  breast-fed  or  bottle-fed,  and  if  breast-fed,  how  long  breast  feed- 
ing was  continued,  when  partial  bottle  feeding  was  begun,  and  when 
exclusive  bottle  feeding  was  instituted.  If  the  story  told  by  the 
mother  suggests  that  the  illness  of  the  child  is  in  any  way  connected 
with  nutrition,  or  if  the  problem  presented  is  one  of  feeding,  all  the 
data  concerning  the  diet  history  should  be  obtained  down  to  the 
minutest  detail.  Each  method  of  artificial  feeding  used  should  be 
ascertained,  with  a  full  account  of  just  how  each  food  was  prepared 
for  the  baby,  and  the  various  mixtures  used  in  home  modification 
should  be  translated  by  the  physician  into  terms  of  the  percentages 
of  the  various  food  elements.  The  diet  of  the  child  after  the  first 
5 


66  Disease  in  Early  Life 

year  should  be  taken  up  in  similar  detail.  The  symptoms  exhibited 
by  the  child  with  each  change  of  food  should  be  ascertained.  In 
particular,  inquiry  should  be  made  as  to  gain  or  loss  in  weight,  vomit- 
ing or  regurgitation,  the  daily  number  and  character  of  the  intestinal 
discharges,  colic  and  flatulence,  and  whether  the  child  was  satisfied 
or  hungry.  These  inquiries  should  be  brought  up  to  include  the 
food  which  the  child  is  now  taking. 

Development. — The  best  idea  of  development  is  to  be  obtained 
from  the  weight  record,  if  there  is  one.  In  addition,  inquiry  should 
be  made  as  to  the  appearance  of  the  most  prominent  landmarks  of 
normal  development.  For  physical  development,  these  are  the  time 
and  order  of  appearance  of  the  teeth,  and  the  age  at  which  the  child 
could  first  hold  up  its  head  unsupported,  sit  unsupported,  creep, 
stand,  and  walk.  Mental  development  is  estimated  by  the  age  at 
which  the  child  could  first  recognize  the  mother  or  nurse,  recognize 
the  bottle,  seize  and  handle  objects,  understand  the  meaning  of  words, 
and  speak  words,  short  sentences,  and  connected  speech. 

Illnesses. — All  previous  acute  illnesses  should  be  noted,  particu- 
larly the  acute  infections,  with  the  dates.  Details  as  to  the  dura- 
tion, severity,  and  complications  of  each  attack  should  be  obtained 
It  is  also  advisable  to  learn  whether  the  child  is  particularly  liable 
to  certain  varieties  of  disorder,  particularly  those  affecting  the  upper 
respiratory  tract,  the  digestive  system,  and  the  nervous  system. 
Under  the  first  are  included  frequent  colds,  tonsillitis,  adenoid  opera- 
tions, earache  or  otitis  media,  croup,  and  bronchitis.  Under  the 
second  are  included  attacks  of  vomiting,  diarrhea,  stomachache,  and 
"bilious"  attacks.  Under  the  third  are  included  restlessness,  in- 
somnia, night  terrors,  convulsions,  and  chorea.  The  date  of  the 
last  successful  vaccination  should  also  be  ascertained. 

THE  PRESENT  ILLNESS.— The  details  of  the  present  illness 
are  obtained  from  the  story  of  the  mother  or  nurse,  and  from  the 
cross-examination  of  the  physician,  which  deSnes  the  various  symp- 
toms. The  most  important  point  in  the  history  of  the  present  ill- 
ness is  that  of  duration.  The  date  of  appearance  and  duration  of 
each  symptom  should  be  exactly  defined,  and  these  details  are  often 
not  volunteered  by  the  mother,  but  have  to  be  obtained  on  cross- 
examination.  The  character  of  the  onset  of  disease  in  children  is  one 
of  the  most  important  points  in  diagnosis,  and  whether  the  onset 
was  gradual  or  abrupt  must  be  carefully  ascertained.  This  can  often 
be  done  only  by  asking  when  the  patient  was  last  quite  well,  and 
what  was  the  first  symptom  of  illness  noted  by  the  mother.  The 
sequence  of  subsequent  symptoms  can  then  usually  be  clearly  ob- 
tained. Individual  symptoms  must  be  analyzed  as  to  their  time 
and  mode  of  onset,  frequency,  character,  severity,  and  duration. 


Physical  Examination  67 

After  the  story  of  the  mother  and  the  cross-examination  analyz- 
ing the  symptoms  are  finished,  it  is  advisable  to  conclude  the  his- 
tory of  the  present  illness  with  a  few  general  questions  as  to  the 
functions  of  the  various  physiological  systems  of  the  body,  which 
have  not  been  included  in  the  story  of  the  mother  or  nurse,  nor  in 
the  physician's  cross-examination.  The  digestive  system  may  be 
investigated  by  questions  as  to  appetite,  the  bowels,  vomiting,  colic, 
flatulence  and  abdominal  pain;  the  respiratory  system  by  questions 
as  to  cough,  dyspnoea,  respiratory  obstruction,  and  pain  in  the 
chest;  the  circulatory  system  by  questions  as  to  shortness  of  breath, 
precordial  pain,  palpitation,  and  edema;  the  nervous  system  by 
questions  as  to  headache,  night  terrors,  restlessness,  insomnia,  con- 
vulsions, and  paralysis;  the  urinary  system  by  questions  as  to  the 
frequency  and  amount  of  micturition,  pain  on  micturition,  and  the 
amount  and  appearance  of  the  urine. 

Finally,  the  mother  or  nurse  should  be  asked  what  in  her  opinion 
is  the  chief  complaint^  the  symptom  which  has  mainly  caused  her  to 
seek  medical  assistance,  and  which  most  requires  relief. 

THE  PHYSICAL  EXAMINATION 

If  the  history  of  the  symptoms  in  the  young  child  is  of  less  diag- 
nostic significance  than  in  the  adult,  the  physical  examination  is 
of  proportionately  greater  importance. 

METHOD  OF  EXAMINING  A  CHILD.— The  method  of  exam- 
ining a  child  is  quite  different  from  that  pursued  with  adults.  In 
the  first  place,  the  order  of  examination  is  different.  The  child  will 
be  either  crying  or  not  crying.  If  it  be  not  crying,  it  is  best  to  begin 
with  that  part  of  the  physical  examination  with  which  crying  most 
interferes.  Crying  interferes  most  with  the  palpation  of  the  abdomen, 
and  next  with  the  auscultation  of  the  heart.  If  the  physician  is  accus- 
tomed to  the  examination  of  children,  crying  will  not  interfere  with 
the  auscultation  of  the  lungs,  but  it  is  sometimes  useful  to  auscult 
the  lungs  with  the  child  quiet  as  well  as  crying.  Consequently,  if 
the  child  be  quiet,  it  is  best  to  palpate  the  abdomen,  auscult  the 
heart,  and  then  auscult  the  lungs,  at  the  very  beginning  of  the  exam- 
ination. If  the  child  be  crying,  these  examinations  should  be  post- 
poned till  the  end,  in  the  hope  that  the  child  will  stop  crying.  The 
examination  of  the  mouth,  throat,  and  ears  should  always  be  post- 
poned to  the  end,  for  if  the  child  be  not  crying  and  resisting,  this 
examination  will  almost  certainly  cause  it  to  do  so. 

The  time  which  is  consumed  in  the  physical  examination  of  a 
child  is  important.  Prolonged  handling  of  a  child,  or  a  prolonged 
struggle  with  a  resisting  child,  is  very  harrowing  to  the  mother.  In 
the  adult,  the  element  of  time  is  not  so  important,  but  the  pediatrist 


68  Disease  in  Early  Life 

must  accustom  himself  to  make  his  examination  quickly.  Thor- 
oughness must  not  be  sacr'liced,  but  a  rapid  deftness  in  physical 
examination  is  a  great  asset  in  dealing  with  children.  This  can  be 
gained  by  practice,  and  by  a  thorough  knowledge  of  just  how  each 
part  should  be  examined,  and  just  how  the  child  should  be  held.  It 
is  not  a  good  plan  with  children  to  make  the  physical  examination 
before  taking  the  history.  The  history  often  brings  out  informa- 
tion which  will  greatly  modify  the  relative  time  spent  in  different 
parts  of  the  physical  examination.  It  is  not  necessary,  for  example, 
to  spend  a  long  time  on  the  examination  of  the  heart  and  lungs  in 
a  case  which  is  obviously  one  of  nutrition,  nor  in  the  testing  of  all 
the  functions  of  the  nervous  system  in  a  case  which  is  obviously 
one  of  infection  of  the  respiratory  tract.  Sufi&cient  attention,  how- 
ever, should  be  paid  to  all  parts  of  the  examination,  to  insure  that 
nothing  be  overlooked. 

The  manner  in  which  the  examination  is  approached  by  the  physi- 
cian makes  a  great  difference  in  the  handling  of  a  sick  child.  He 
should  not  approach  it  strenuously,  nor  tower  over  it,  nor  make 
any  parade  of  preparation.  It  is  best  not  to  notice  the  child  at 
first,  but  to  talk  with  the  mother.  Then  the  physician  may  notice 
and  handle  the  child's  playthings.  It  is  often  a  good  plan  to  give 
the  stethoscope  to  the  child  to  hold  at  the  beginning  of  the  examina- 
tion, for  if  this  is  done  it  will  not  be  so  terrifying  when  the  time 
comes  to  use  it.  It  is  also  often  helpful  to  perform  any  act  of  hand- 
ling like  percussion,  or  the  application  of  the  stethoscope,  first  on  a 
doll,  teddy  bear,  or  even  on  the  mother,  before  performing  it  on  the 
child.  By  smiling  and  making  a  sort  of  game  of  the  examination, 
a  good  understanding  with  the  child  can  often  be  maintained  for  a 
considerable  time. 

If,  however,  friendly  relations  cannot  be  maintained,  and  the 
child  begins  to  cry,  and  resist,  all  blandishments  should  be  stopped, 
and  the  physician  should  proceed  to  complete  the  examination  as 
rapidly  as  possible.  It  is  often  difficult  to  get  mothers  to  cooperate 
under  these  conditions,  as  they  want  to  avoid  using  force,  and  to 
continue  their  coaxing  methods.  At  this  stage,  coaxing  is  usually 
of  no  avail,  and  the  physician  should  tell  the  mother  exactly  what 
he  wants  her  to  do,  and  just  how  she  must  hold  the  child,  and  should 
make  her  do  just  what  he  tells  her.  This  method,  though  it  involves 
the  use  of  forcible  restraint,  is  much  better  in  the  end,  as  the  exami- 
nation is  shortened  instead  of  being  prolonged  in  a  confusion  of 
crying,  struggling,  and  coaxing. 

In  many  cases,  the  best  position  for  the  child  undergoing  physical 
examination  is  recumbent  on  a  firm  surface.  The  recumbent  posi- 
tion on  the  back  is,  however,  only  essential  when  the  abdomen  is 
being  examined,  and  in  an  infant,  this  can  be  obtained  with  the 


Physical  Examination 


69 


child  lying  across  the  mother's  knees.  Placing  the  child  on  its  back 
on  a  table  or  bed  is  often  more  apt  to  frighten  it  than  if  it  be  examined 
on  its  mother's  lap,  and  in  many  cases  it  is  better  to  conduct  the 
examination  with  the  child  in  the  latter  position.  This  is  especially 
the  case  in  examinations  conducted  in  the  home,  where  good  exam- 
ining tables  are  not  always  available. 

Examination  of  a  Young  Infant  on  the  Mother's  Lap. — The 
naked  child  is  first  placed  on  its  back  across  the  mother's  knees' 
and  the  front  of  the  body  is  examined.  If  the  child  be  quiet,  the 
physician  begins  with  the  palpation  of  the  abdomen,  and  follows 
with  the  auscultation  of  the  heart  and  lungs.  Then  he  proceeds  to 
the  general  examination  of  the  body,  and  to  the  examination  of  the 


Fig.  14 


Proper  positijn  fur  the  child  when  examined  in  a  sitting  position 

cranium,  facies,  eyes,  and  neck.  Next  he  completes  the  examination 
of  the  front  of  the  chest  and  the  abdomen,  and  examines  the  extremi- 
ties and  reflexes.  The  child  is  then  turned  face  down  and  the 
back  of  the  chest,  the  spine,  the  buttocks,  and  the  anus  are  exam- 
ined.    The  mouth,  throat,  and  ears  are  examined  last. 

Examination  of  an  Older  Infant  or  Young  Child  on  the 
Mother's  Lap. — The  child  should  sit  upon  the  lap  of  the  mother 
or  nurse,  leaning  back  upon  the  middle  of  her  body,  not  held  in  the 


70 


Disease  in  Early  Life 


hollow  of  one  arm.  In  this  position,  the  physician  first  notes  the 
points  included  in  the  general  examination  of  the  body.  He  next 
examines  the  head  as  far  as  external  inspection  and  palpation  are 
concerned,  which  includes  the  cranium,  facies,  eyes,  and  neck,  leav- 
ing the  mouth,  throat  and  ears  for  the  end.  He  then  examines  the 
front  of  the  chest,  the  extremities,  and  the  reflexes.  If  the  child 
struggles,  or  attempts  to  interfere  with  the  examination  by  grabbing 
at  the  stethoscope  or  at  the  hands  of  the  physician,  the  mother  should 
be  taught  to  grasp  each  of  the  child's  arms  firmly  just  above  the 
elbows,  and  to  hold  them  close  to  the  sides  of  the  body.  When  the 
examination  of  the  front  of  the  body  is  complete,  the  child  should 


Fig.  15 


Method  of  holding  an  infant  for  examination  of  the  back  of  the  chest 

be  turned  with  its  back  to  the  physician,  and  held  upright  if  an 
infant,  kneeling  if  larger,  with  its  head  on  the  mother's  shoulder, 
and  her  arm  around  its  hips.  In  this  position  the  back  of  the  chest 
is  examined.  The  diaper  is  then  removed,  and  the  baby  is  placed 
on  its  back  across  the  mother's  knees,  for  examination  of  the  abdo- 
men, then  turned  face  down  for  examination  of  the  spine,  buttocks 
and  anus.  If  the  child  be  too  large  to  lie  across  the  mother's  knees, 
this  last  part  of  the  examination  must  be  performed  on  a  table  or 
firm  bed. 


Physical  Examination 


71 


Examination  Upon  a  Table.— This  is  performed  in  the  same 
manner  as  with  the  young  child  across  its  mother's  knees.  If  the 
child  struggles  or  resists,  the  mother  or  nurse  should  stand  on  the 
opposite  side  of  the  table,  and  place  one  hand  on  the  child's  two 
hands,  holding  them  stretched  above  its  head,  and  pinning  them 
firmly  to  the  table,  while  the  other  hand  grasps  both  ankles.  If 
the  child  is  too  big  to  be  held  in  this  way,  the  mother  or  nurse  should 
stand  at  the  head  of  the  table,  and  grasping  each  of  the  child's  hands 
in  one  of  hers,  should  hold  them  firmly  to  the  table  close  to  its  sides. 
This  will  prevent  the  child  from  getting  up  or  turning  over,  but  the 
physician  must  be  prepared  to  dodge  the  kicking  heels.  It  is  some- 
times advisable,  in  examining  the  back  of  the  chest,  to  have  the 
child  sitting  on  the  table  with  its  back  bent  forward,  rather  than 
lying  upon  its  face. 

Fig.  1 6 


Position  for  examination  of  the  throat 

Examination  of  the  Mouth  and  Throat.— The  child  should  sit 
upright  on  the  lap  of  the  mother  or  nurse,  facing  the  light  if  a  head- 
mirror  is  not  used,  with  the  light  behind  if  a  head-mirror  is  used. 
The  strongest  possible  light  is  desirable.  The  essential  feature  of 
the  position  for  the  examination  of  the  throat  is  that  the  child  shall 
be  held  with  its  back  reclining  against  the  middle  of  the  mother's 
or  nurse's  body,  not  in  the  crook  of  her  arm.     The  mother  then 


72 


Disease  in  Early  Life 


grasps  both  the  child's  hands  in  one  of  hers,  and  places  her  other 

hand  on  the  child's  forehead,  holding  its  head  firmly  against  her 

body.     The  child's  legs  are  held  between  the  mother's  knees.     This 

position  leaves  both  the  physician's  hands  free,  which  is  important 

when  cultures  are  to  be  taken.     If  no  culture  is  to  be  taken,  the 

physician  can  use  his  free  hand  in  helping  to  steady  the  head,  or  in 

bringing  it  to  the  proper  angle  by  pulling  slightly  forward  on  the 

neck.     The  teeth  and  mucous  membrane   of   the  mouth  are  first 

examined,  and  then  the  tongue  is  depressed  for  the  examination  of 

the  throat. 

A  young  infant  can  be  held  for  the  throat  examination  with  the 

mother  or  nurse  standing.     This  permits  her  to  approach  close  to  a 

window  or  Hght.     The  child  is  swathed  in  a  blanket,  and  is  held 

with  its  back  against  the  mother's  shoulder,  in  the  position  shown 

in  the  illustration. 

Fig.  17 


Method  of  holding  an  infant  for  examination  of  tlie  mouth  and  tliroat 
This  allows  the  child  to  be  held  in  a  good  light  close  to  a  v.-indow 

The  various  points  of  importance  to  be  especially  noted  by  a 
physician  in  the  examination  of  a  child",  present  certain  differences, 
which  should  be  familiar  to  every  one  practicing  among  children. 

GENERAL  INSPECTION  OF  THE  BODY.— This  is  accom- 
phshed  by  inspection,  almost  at  a  glance,  and  by  a  rapid  palpation 
of  the  neck,  axillae,  inguinal  regions,  and  muscles.     It  includes  the 


Physical  Examination  73 

nutrition,  size,  weight,  skin,  position  of  the  body,  mental  condition, 
lymph  nodes,  bones,  joints,  and  muscles. 

The  Nutrition,  Size  and  Weight,  are  estimated  by  inspection. 
This  first  estimate  will  be  confirmed  later  by  weighing  and  measure- 
ment. The  amount  of  subcutaneous  fat  can  be  judged  at  this  time 
by  inspection  and  palpation.  It  is  essential  that  the  physician  should 
be  familiar  with  the  growth  of  the  normal  child  in  length  and  weight, 
as  described  in  the  section  on  Normal  Development. 

The  Skin. — The  skin  should  be  thoroughly  examined  for  visible 
lesions.  The  most  significant  in  early  life  are  eruptions,  ecchymoses, 
desquamation,  cicatrices,  edema,  sclerema,  and  angioneurotic  edema. 
The  color  of  the  skin  should  be  noted  for  pallor,  cyanosis,  and  icterus. 
It  must  be  remembered  that  the  color  of  the  skin  is  not  so  reliable 
an  indication  of  anemia  and  cyanosis  as  is  that  of  the  visible  mucous 
membrane.  Edema  is  recognized  by  the  fact  that  the  swelling  is 
most  marked  about  the  eyes,  on  the  dorsum  of  the  feet,  on  the  legs, 
and  on  dependent  portions,  that  the  color  of  the  skin  is  normal  or 
pale,  that  the  swelling  is  not  hard  nor  accompanied  by  rigidity,  and 
that  it  pits  on  pressure.  Sclerema  is  seen  only  in  the  newborn,  or 
in  very  feeble  infants,  the  color  of  the  skin  is  normal  or  slightly 
bluish,  the  swelHng  is  hard  and  accompanied  by  rigidity,  and  it 
does  not  pit  on  pressure.  Angioneurotic  edema  is  usually  circum- 
scribed, and  somewhat  pink  in  color,  is  often  accompanied  by  itching, 
and  does  not  pit  on  pressure.  It  should  also  be  noted  whether  the 
skin  is  hot  or  cold,  moist  or  dry,  smooth  or  rough,  thin  or  thick. 
Rarer  lesions  sometimes  seen  in  children  are  emphysema,  rheumatic 
nodules,  tumors,  moles,  and  parasites.  The  bluish-black  "mongolian 
spots,"  sometimes  seen  in  the  sacral  and  glutial  regions,  have  no 
diagnostic  significance. 

Position  of  the  Body. — This  is  often  of  diagnostic  significance, 
and  should  always  be  noted.  A  child  may  have  a  tendency  to  lie 
on  one  side  or  the  other,  to  lie  with  the  legs  drawn  up  or  the  limbs 
in  an  abnormal  position,  or  the  spine  may  be  abnormally  curved 
either  forward  or  backward. 

Mental  Condition. — This  is  one  of  the  most  important  points 
in  the  physical  examination  of  the  sick  child.  A  fairly  accurate 
estimate  of  the  mental  condition  can  usually  be  made  by  inspection 
in  the  general  examination  of  the  body,  although  at  times  abnor- 
malities can  only  be  recognized  by  the  special  testing  of  the  condi- 
tion of  the  nervous  system  which  is  carried  out  later.  The  physician 
should  note  carefully  the  child's  reaction  to  its  surroundings,  and 
in  particular,  how  it  reacts  to  the  examination.  Thorough  famili- 
arity with  the  behavior  of  normal  children  at  every  age  is  essential. 
The  physician  should  note  whether  the  child  follows  his  movements 


74  Disease  in  Early  Life 

intelligently,  and  whether  it  resists  intelligently  or  mechanically. 
By  watching  it  closely,  he  can  usually  estimate  its  mental  develop- 
ment, and  can  recognize  the  presence  of  such  abnormalities  as  apathy, 
stupor,  or  delirium. 

The  Lymph  Nodes. — The  cervical,  axillary,  epitrochlear,  and 
inguinal  lymph  nodes,  may  be  rapidly  examined  by  palpation,  and 
this  can  well  be  done  during  the  general  inspection  of  the  body,  as 
it  does  not  usually  frighten  the  child,  and  is  a  good  preparation  for 
the  palpation  and  percussion  which  is  soon  to  follow.  The  lymph 
nodes  are  examined  chiefly  for  enlargement,  tenderness,  and  suppu- 
ration. Enlargement  of  the  lymph  nodes  may  be  general  or  local. 
It  must  be  remembered  that  general  enlargement  of  the  peripheral 
lymph  nodes  in  infancy  is  not  of  the  same  significance  as  in  adult 
life.  It  occurs  in  practically  all  disturbances  of  nutrition,  may  in- 
clude the  epitrochlear  and  occipital  nodes,  and  at  this  age  does  not 
point  to  syphilis,  tuberculosis,  or  primary  disease  of  the  blood.  In 
later  childhood,  general  enlargement  of  the  peripheral  lymph  nodes 
has  the  same  significance  as  in  adults. 

Local  enlargement  of  the  peripheral  lymph  nodes  is  particularly 
common  in  early  life.  It  has  the  same  significance  both  in  infancy 
and  childhood  as  in  adult  life.  The  most  common  causes  are,  (i) 
acute  lymphadenitis  due  to  the  absorption  of  toxic  products  from 
an  infection  in  the  area  draining  into  the  nodes  involved;  (2)  acute 
infection  of  the  lymph  nodes  themselves,  usually,  leading  to  sup- 
puration; and  (3)  tuberculosis.  The  lymph  nodes  of  the  neck  are 
by  far  the  most  frequently  involved  in  local  enlargement,  and  are 
almost  the  only  peripheral  lymph  nodes  involved  in  tuberculosis. 

The  Bones  and  Joints. — The  size,  contour,  and  general  appear- 
ance of  the  bones  and  joints  can  be  estimated  by  inspection  during 
the  general  examination  of  the  body.  If  there  is  nothing  in  the 
history  to  suggest  any  abnormality  of  the  bones  and  joints,  their 
routine  examination  can  well  be  completed  at  this  time.  The  long 
bones  and  joints  should  be  felt,  and  pressure  should  be  applied. 
The  chief  signs  to  be  looked  for  are  deformities,  swelling,  tenderness, 
and  redness.  The  significance  of  these  various  signs  will  be  discussed 
under  the  examination  of  the  extremities. 

The  Muscles. — The  condition  of  the  muscles  can  be  estimated 
by  inspection  and  palpation  at  the  same  time  as  the  nutrition  and 
amount  of  subcutaneous  fat  are  noted.  The  principal  abnormal 
conditions  in  the  muscles  are  atrophy,  softness,  and  tenderness.  The 
first  is  seen  in  many  nutritional  disturbances,  particularly  in  those 
of  gastro-intestinal  origin.  A  soft,  flabby,  relaxed  condition  of  the 
muscles  is  seen  also  in  nutritional  disturbances,  particularly  in  rickets. 
Muscular  tenderness  is  most  often  a  sign  of  over-use.     In  the  back 


Physical  Examination 


75 


or  extremities  it  is  most  often  seen  after  over-exercise.  Tenderness 
of  the  muscles  of  the  abdominal  wall  is  met  with  after  excessive 
coughing  or  vomiting. 

Temperature. — The  period  of  the  examination  at  which  the 
temperature  is  taken  depends  on  circumstances.  If  the  child  is 
quiet,  it  is  often  best  to  postpone  it  till  the  end  of  the  general  exami- 
nation, just  before  the  examination  of  the  throat.  It  should  always 
be  taken  either  by  mouth  or  by  rectum;  temperature  taken  in  the 
axilla  or  groin  cannot  be  relied  upon.  Whenever  a  child  is  too  young 
to  hold  the  thermometer  properly  in  the  mouth,  the  temperature 
should  be  taken  by  rectum. 

Fig.  1 8 


Obtaining  pulse  rate  in  infants 

Pulse. — This  is  usually  best  examined  during  the  general  examina- 
tion of  the  body,  but  if  the  attempt  to  take  the  pulse  appears  to  annoy 
the  child,  it  can  well  be  postponed  until  later,  and  taken  in  connection 
with  the  examination  of  the  heart,  the  limbs,  or  the  taking  of  the 
temperature.  The  points  to  be  noted  are  the  rate,  rhythm,  volume, 
compressibihty,  and  character  of  the  wave.  In  cases  showing  signs 
of  circulatory  disturbance,  the  radial  pulse  should  be  compared  with 
the  ausculted  heart  sounds,  and  the  capillary  pulse  should  be  sought. 

The  normal  pulse  rate  at  the  different  ages  is  given  in  the  section 
on  Normal  Development.     It  must  be  remembered  that  an  entirely 


76  Disease  in  Early  Life 

different  standard  from  that  of  adults  must  be  used  in  estimating 
abnormalities  of  the  pulse  in  early  life.  Increase  in  the  rate  of 
the  pulse  is  of  much  less  significance  in  infancy  and  early  child- 
hood. The  rate  tends  to  increase  very  markedly  from  compar- 
atively slight  causes,  such  as  exertion,  excitement,  or  any  slight 
disorder.  Given  any  such  cause,  the  absolute  rate  of  the  pulse  is 
not  very  significant.  If,  however,  in  any  severe  disease  the  rate 
of  the  pulse  is  continually  increasing,  it  points  toward  an  increasing 
severity  of  the  underlying  pathological  condition.  The  ryhthm  of 
the  pulse  is  also  very  easily  disturbed;  the  pulse  is  normally  irreg- 
ular in  the  newborn,  and  easily  becomes  irregular  from  slight  causes 
in  infancy  and  early  childhood.  The  volume  and  compressibility  are 
more  significant  as  evidence  of  the  condition  of  the  circulation. 

The  Respiration. — The  respiration  is  best  observed  as  a  part  of 
the  general  inspection,  and  should  be  examined  as  to  rate,  rhythm, 
and  character.  The  rate  varies  normally  with  the  age,  with  the 
individual,  and  according  to  whether  the  child  is  active  or  quiet, 
asleep  or  awake.  It  is  therefore  difficult  to  give  a  standard  which 
is  correct  for  the  different  ages;  an  approximate  standard  is  given  in 
the  section  on  Normal  Development.  Irregularity  of  the  respira- 
tion, which  is  so  prominent  in  the  newborn,  continues  normally  dur- 
ing the  first  two  years,  and  is  not  significant  in  infancy.  In  later 
childhood,  irregularity  is  more  important,  and  Cheyne- Stokes'  types 
of  diagnostic  significance  can  often  be  recognized.  Even  in  infants 
a  regular  irregularity  is  suggestive. 

The  points  to  be  noted  in  connection  with  the  character  of  the 
respiration,  are  whether  it  is  painful,  shallow,  costal,  or  diaphrag- 
matic. Painful  respiration  is  betrayed  by  a  contraction  of  the 
child's  face,  and  by  an  expiratory  groan  or  grunt.  Shallow  respira- 
tion is  not  of  much  significance,  as  this  is  a  normal  form  in  young 
children.  Also  up  to  the  seventh  year  the  respiration  is  normally 
predominantly  diaphragmatic  in  character.  The  relation  of  inspira- 
tion to  expiration  should  also  be  noted. 

Dyspnoea  in  early  life  is  of  two  types,  obstructive  and  non- 
obstructive. Each  of  these  types  may  be  further  subdivided  into 
inspiratory  and  expiratory.  In  the  non-obstructive  type,  the  respi- 
ration is  increased  in  rate,  and  is  often  labored  in  character,  but  is 
not  accompanied  by  any  stridor,  or  other  evidence  of  mechanical 
obstruction.  It  is  seen  in  infections  of  the  lungs  and  pleura,  in 
disease  of  the  heart,  and  in  certain  conditions  of  toxemia.  Although 
often  accompanied  by  an  expiratory  grunt,  the  type  is  mainly  in- 
spiratory in  these  conditions,  the  principal  muscular  eft'ort  being 
that  of  inspiration.  In  some  toxic  conditions,  such  as  acidosis  and 
diabetic  coma,   the  inspiratory  character  is  so  marked   that  it  is 


Physical  Examination  77 

called  ''air-hunger."  Expiratory  dyspnoea  is  seen  chiefly  in  asthma, 
in  which  the  expiration  is  labored,  and  though  wheezing  is  heard, 
there  is  no  evidence  of  any  localized  obstruction. 

In  the  obstructive  type,  there  is  a  stridor,  or  noise,  suggesting  the 
presence  of  a  localized  narrowing  of  the  air  passages.  The  location 
and  character  of  this  sound  is  evidence  of  the  location  and  character 
of  the  obstruction.  When  the  sound  is  a  coarse  stridor  without 
musical  tone,  and  appears  to  come  from  the  throat  or  nose,  the  ob- 
struction is  usually  in  the  nose  or  naso-pharynx.  The  dyspnoea  is 
usually  inspiratory,  when  the  obstruction  is  due  to  such  conditions 
as  rhinitis,  adenoids,  or  enlarged  tonsils,  but  in  retropharyngeal 
abscess  the  most  marked  sound  is  usually  heard  during  expiration. 
When  the  sound  is  crowing,  with  a  more  or  less  musical  tone,  the 
obstruction  is  in  the  larynx,  and  the  dyspnoea  is  of  a  marked  in- 
spiratory type.  Severe  inspiratory  dyspnoea  is  further  to  be  recog- 
nized by  inspiratory  retraction  of  the  supra-clavicular,  intercostal, 
and  epigastric  spaces.  It  must  be  remembered,  however,  that  in- 
spiratory recession  of  the  epigastrium  is  normal  in  the  early  months 
of  life.  When  the  stridor  comes  from  the  chest,  it  is  usually  less 
marked.  The  commonest  cause  is  pressure  upon  the  trachea  or 
primary  bronchi  by  an  enlarged  thymus,  or  enlarged  mediastinal 
lymph  nodes.     The  dyspnoea  is  usually  of  the  expiratory  type. 

THE  HEAD. — After  the  general  examination  of  the  body  has 
been  completed,  the  physician  proceeds  to  the  examination  of  the 
various  anatomical  parts.  This  should  be  carried  out  systematically 
in  a  definite  order.     It  is  convenient  to  begin  with  the  head. 

The  Cranium. — The  cranium  should  be  examined  with  reference 
to  size,  shape,  the  fontanelles,  the  sutures  and  ossification,  the  hair, 
and  the  superficial  veins  of  the  scalp. 

The  absolute  size  of  the  head  varies  with  the  individual,  and  the 
important  point  is  the  relative  size  in  comparison  with  the  thorax. 
The  normal  relations  are  given  in  the  section  on  Normal  Develop- 
ment. The  most  common  cause  of  enlargement  of  the  cranium  is 
hydrocephalus,  and  of  an  abnormally  small  cranium  is  microcephalus. 

The  most  common  abnormalities  in  the  shape  of  the  cranium  are 
those  caused  by  rickets  and  hydrocephalus.  They  are  recognized  by 
inspection,  and  will  be  described  in  connection  with  those  diseases. 
Certain  deformities  resulting  from  compression  during  labor  are  often 
present  at  birth,  but  disappear  during  the  early  weeks.  There  is 
also  a  marked  congenital  asymmetry  of  the  head  seen  at  times, 
which  persists  for  a  number  of  years,  but  usually  disappears  before 
the  child  is  seven  years  old.  Flattening  of  the  back  or  side  of  the 
head  may  occur  as  a  result  of  the  child  lying  too  much  in  one  posi- 
tion.    This  is  easily  recognized  and  corrected. 


78  Disease  in  Early  Life 

The  fontanelles  are  examined  by  palpation  with  reference  to  size, 
delay  in  closure,  depression,  and  bulging.  An  open  posterior  fonta- 
nelle  after  the  sixth  week,  and  an  open  anterior  fontanelle  after  the 
nineteenth  month,  are  abnormal.  Delay  in  closure,  or  abnormally 
large  size  of  the  fontanelles  is  due  most  commonly  to  rickets,  and 
next,  to  hydrocephalus,  but  is  sometimes  seen  as  a  pecuharity  in 
normal  children.  It  is  well  to  measure  the  diameters  of  the  anterior 
fontanelle;  they  should  not  be  over  2.5  by  3  cm.  Depression  of  the 
fontanelle  is  caused  by  a  decrease  in  the  quantity  of  intracranial 
fluid,  and  is  seen  chiefly  in  acute  diarrhea,  and  chronic  conditions 
of  malnutrition.  Bulging  of  the  fontanelle  is  caused  by  increased  in- 
tracranial pressure,  and  is  seen  chiefly  in  meningitis  and  hydrocephalus, 
sometimes  in  brain  tumor,  brain  abscess,  and  brain  hemorrhage. 

The  sutures  are  examined  for  failure  to  close,  and  for  overlapping. 
Except  that  the  upper  part  of  the  frontal  suture  may  normally 
remain  open  for  a  few  weeks,  any  separation  of  the  cranial  bones 
is  abnormal.  It  is  seen  most  often  in  rickets  and  hydrocephalus. 
The  cranium  should  also  be  examined  for  cranio-tabes — a  softening  of 
the  bones  of  the  skull.  It  is  recognized  by  pressure  upon  various 
parts  of  the  cranium  with  the  tips  of  the  fingers.  Soft  spots  are 
found  which  give  the  sensation  of  tightly  stretched  parchment. 
They  are  found  most  often  about  the  fontanelles  and  sutures,  and 
over  the  occipital  and  parietal  bones.  Craniotabes  is  usually  a  sign 
of  rickets,  but  is  sometimes  seen  in  syphihs.  If  it  be  present  at 
birth,  it  represents  a  congenital  developmental  anomaly  rather  than 
rickets  or  syphilis. 

The  hair  is  examined  as  to  amount  and  texture.  The  fine  hair 
present  at  birth  is  not  permanent,  but  is  replaced.  There  is  great, 
variation  in  the  period  when  this  occurs,  so  that  while  some  babies 
soon  have  a  thick  growth  of  hair,  others  remain  bald  for  a  consider- 
able time.  Loss  of  hair  on  the  back  of  the  head  is  a  sign  of  restless- 
ness, from  whatever  cause.  Coarse  hair  should  suggest  the  possi- 
bility of  cretinism. 

The  superficial  veins  of  the  scalp  are  examined  for  enlargement. 
This  is  a  constant  sign  in  chronic  internal  hydrocephalus,  and  is 
often  seen  in  syphihs.  It  is  sometimes  seen  in  rickets  and  other 
nutritional  disturbances. 

The  Facies. — Inspection  of  the  face  often  reveals  abnormal  signs. 
The  most  important  point  to  be  noted  is  the  facial  expression,  which 
often  gives  useful  evidence  as  to  the  mental  condition.  The  expres- 
sion may  be  placid,  stupid,  anxious,  or  pinched.  There  are  various 
types  of  facies  which  are  difficult  to  describe,  but  which  are  easily 
recognized  from  experience.  The  most  familiar  is  the  adenoid  facies, 
characterized  by  open  mouth,  and  stupid,  vacant  look,  and  sometimes 


Physical  Examination  •   79 

by  a  flattened  bridge  of  the  nose,  narrowing  of  the  face  toward  the 
chin,  prominent  upper  hp,  and  obhteration  of  the  naso-labial  folds. 
There  is  an  ''abdominal  fades,"  often  seen  in  severe  abdominal  dis- 
orders such  as  peritonitis  or  intussusception,  which  is  characterized 
by  a  peculiar  sunken-eyed  appearance  difhcult  to  describe,  but  easy 
to  recognize.  There  is  also  a  cerebral  facies,  seen  in  patients  with 
severe  acute  intracranial  lesions  such  as  meningitis,  characterized  by 
a  peculiar  staring  expression. 

Facial  paralysis  is  recognized  by  inspection  of  the  face,  but  is 
often  overlooked  unless  the  child  laughs  or  cries.  In  repose,  the 
chief  sign  is  obhteration  of  the  naso-labial  fold  on  one  side;  on  crying, 
the  lessened  movement  on  one  side  is  plainly  apparent. 

The  Eyes  are  inspected  for  inflammation  of  the  conjunctiva, 
icteric  staining  of  the  conjunctiva,  conjunctival  discharge,  strabismus, 
nystagmus,  and  inequahties  of  the  pupil. 

Inflammation  and  conjunctival  discharge  suggest  infection,  and  a 
purulent  discharge  should  always  be  examined  bacteriologically. 
Nystagmus  .and  irregularities  of  the  pupils  suggest  either  disease  of 
the  central  nervous  system,  or  local  disease  of  the  eye.  I  have 
often  seen  nystagmus  in  albinos.  In  connection  with  strabismus,  it 
should  be  remembered  that  coordination  is  not  well  estabhshed  in 
young  infants,  and  a  normal  baby  does  not  fix  its  eyes  until  it  begins 
to  recognize  objects  at  about  the  age  of  six  weeks,  or  even  somewhat 
later.  In  these  early  weeks,  temporary  and  varying  strabismus  is 
of  no  diagnostic  significance.  A  constant  strabismus  is  suggestive 
of  a  congenital  abnormality  of  the  muscles  of  the  eyeball.  In  older 
infants  and  children,  if  strabismus  be  found,  it  is  necessary  to  ascer- 
tain if  the  condition  has  been  present  since  birth,  in  which  case  it 
is  due  to  the  same  local  cause.  If  the  strabismus  has  not  been  pres- 
ent from  birth,  but  has  developed  as  a  symptom  of  the  present  ill- 
ness, it  is  important  in  diagnosis,  pointing  toward  a  disturbance  of 
the  central  nervous  system. 

The  pupillary  reaction  can  best  be  tested  at  this  period  of  the 
examination.  The  test  is  best  performed  either  by  bringing  a  light 
from  above  downward  in  front  of  the  eyes,  or  by  suddenly  snapping 
on  a  pocket  flash-light  held  in  front  of  the  eyes.  The  normal  reac- 
tion to  light  is  present  immediately  after  birth.  Failure  to  react 
suggests  disease  of  the  central  nervous  system.  It  is  useless  to 
attempt  to  test  the  reaction  to  accommodation  in  infants  and  young 
children. 

The  Nose,  in  routine  examination,  is  investigated  by  simple 
external  inspection.  The  most  important  signs  in  diagnosis  are 
widening  of  the  bridge  of  the  nose,  and  discharge  from  the  nostrils. 
In  infancy  and  early  childhood  the  bridge  of  the  nose  is  normally 


80  Disease  in  Early  Life 

slightly  developed  and  relatively  wide,  but  a  pronounced  widening 
is  seen  in  cretinism  and  Mongolian  idiocy.  A  nasal  discharge  in 
infants  as  well  as  children,  is  usually  due  to  a  simple  catarrhal  rhinitis, 
and  should  not  suggest  syphilis  unless  other  signs  be  present.  A 
thin,  irritating,  blood-tinged  discharge,  especially  if  coming  from  one 
nostril,  suggests  nasal  diphtheria,  and  a  culture  should  always  be 
taken.  A  unilateral  discharge  also  suggests  a  foreign  body  in  the 
nostril. 

The  Mouth  is  best  examined  at  the  end  in  connection  with  the 
throat,  but  the  signs  to  be  noted  are  most  conveniently  described 
in  connection  with  the  systematic  examination  of  the  head.  The 
physician  should  first  note  whether  the  mouth  is  kept  open  or  closed. 
An  open  mouth  suggests  obstruction  in  the  nose  or  naso-pharynx, 
most  commonly  from  adenoids,  but  it  should  be  remembered  that 
young  children  when  deeply  interested  often  keep  their  mouths  open. 
The  physician  should  next  inspect  the  lips  as  to  their  color,  and  as 
to  the  presence  of  fissures,  ulcerations,  herpes,  and  deformities.  In 
infants  fissures  and  ulcerations  are  suggestive  of  syphilis;  while  in 
older  children  they  are  usually  due  to  chapping.  Herpes  is  seen  in 
acute  infectious  diseases.     The  most  common  deformity  is  hare-lip. 

The  throat  stick  or  handle  of  a  spoon  is  now  inserted  between  the 
lips,  which  are  retracted  for  the  inspection  of  the  teeth  and  gums. 
The  number  and  arrangement  of  the  teeth  are  noted,  and  compared 
with  the  normal  at  that  age.  The  appearance  of  the  teeth,  whether 
carious  or  deformed,  is  also  noted.  Delay  or  irregularity  in  the 
appearance  of  the  first  set  of  teeth  is  a  sign  of  rickets,  but  may  be 
only  an  inherited  or  individual  peculiarity,  and  should  not  be  attrib- 
uted to  rickets  unless  other  signs  of  the  disease  be  present.  Other 
disturbances  of  nutrition  do  not  usually  cause  delayed  dentition, 
but  may  cause  the  formation  of  imperfect  teeth  with  a  tendency 
toward  early  decay.  The  permanent  teeth  show  similar  changes  if 
nutrition  is  disturbed  in  early  childhood.  The  Hutchinson  teeth, 
characteristic  of  syphilis,  are  seen  only  in  the  second  dentition. 

In  the  inspection  of  the  gums,  the  physician  should  note  their 
color,  and  whether  they  are  swollen,  spongy,  hemorrhagic,  ulcerated, 
or  separated  from  the  teeth.  Hemorrhagic  lesions  of  the  gums  are 
characteristic  of  scurvy,  while  the  other  changes  are  seen  in  the 
various  varieties  of  stomatitis. 

The  tongue  depressor  is  now  inserted  between  the  teeth,  and  the 
cheek  on  each  side  is  retracted  for  inspection  of  the  buccal  mucous 
membrane.  Disease  signs  to  be  particularly  looked  for  are  the 
redness  of  catarrhal  stomatitis^  the  mucous  patches  of  syphilis,  the  Kop- 
lik's  spots  of  measles,  the  eruptions  of  the  exanthemata,  and  the  cJiar- 
acteristic  lesions  of  thrush,  stomatitis  herpetica,  and  ulcerative  stoma- 


Physical  Examination  81 

litis.  There  are  two  appearances  in  young  infants  which  must  not 
be  mistaken  for  any  of  the  above  lesions,  namely,  Epstein's  pearls^ 
and  Bednars  aphthae.  The  former  are  one  or  more  small  white  or 
yellowish-white  nodules  in  the  median  line  of  the  hard  palate  near 
its  junction  with  the  soft  palate,  and  are  accumulations  of  epithelial 
cells.  The  latter  are  symmetrical  erosions  or  ulcerations  of  mechan- 
ical origin  on  each  side  of  the  hard  palate  where  the  mucous  mem- 
brane over  the  tips  of  the  sphenoidal  hamular  processes  is  very  thin. 

The  shape  of  the  roof  of  the  mouth  should  be  noted.  It  is  flatter 
in  infancy  than  in  later  childhood.  While  normal  variations  in  the 
arch  of  the  hard  palate  are  very  great,  excessive  arching  is  suggestive 
of  obstruction  to  nasal  respiration,  the  most  common  cause  being 
adenoids. 

The  tongue  is  next  inspected.  The  physician  should  note  whether 
it  is  pale,  red,  cyanotic,  dry,  moist,  smooth,  rough,  or  coated.  The 
mouth  is  normally  relatively  dry  in  early  infancy.  Later  the  salivary 
secretion  increases  rapidly  in  amount,  and  until  the  infant  learns 
to  swallow  it,  drooling  is  a  normal  condition.  The  tongue  is  nor- 
mally lightly  coated  during  early  infancy.  The  size  of  the  torgue 
should  be  noted.  Enlargement  and  protrusion  may  rarely  represent 
a  congenital  malformation,  but  is  more  often  a  sign  of  cretinism. 
The  tongue  may  show  any  of  the  lesions  characteristic  of  the  various 
forms  of  stomatitis,  and  of  syphilis.  Ulceration  of  the  under  sur- 
face of  the  tongue  about  the  frenum,  as  a  result  of  the  mechanical 
irritation  of  the  lower  incisor  teeth,  is  not  uncommon  in  infancy. 
The  frenum  should  also  be  inspected  for  tongue-tie.  The  mucous 
membrane  of  the  tongue  in  children  may  show  the  peculiar  appear- 
ance of  "geographical  tongue."  Enlargement  of  the  papillae  of  the 
tongue  is  an  important  sign  of  scarlet  fever. 

The  Throat. — The  proper  position  of  the  child  in  the  examina- 
tion of  the  throat  has  already  been  described.  If  the  child  refuses 
to  open  its  mouth,  the  tongue  depressor  can  usually  be  worked  in 
gradually  from  the  side,  being  pushed  in  little  by  little  when  the 
child  cries.  It  is  rarely  necessary  to  pinch  the  nose.  As  soon  as 
the  depressor  is  over  the  tongue,  downward  pressure  will  cause  the 
child  to  open  the  mouth.  It  is  necessary,  in  examining  the  throat, 
to  make  the  child  gag.  This  cannot  be  accomplished  by  pressure 
upon  the  front  or  middle  of  the  tongue,  but  the  depressor  is  placed 
on  the  back  of  the  tongue  and  pressed  downward  and  forward.  The 
physician  should  practice  his  powers  of  observation  so  that  he  sees 
all  there  is  to  see  in  a  brief  space  of  time. 

In  the  examination  of  the  throat,  all  visible  portions  of  the  mucous 
membrane  should  be  inspected  for  redness,  eruptions,  exudate,  ulcera- 
tion, and  membrane.  The  localization  of  any  of  these  signs,  whether 
6 


82  Disease  in  Early  Life 

upon  the  soft  palate,  uvula,  pillars,  tonsils,  or'  posterior  pharyngeal 
wall,  should  be  noted.  Whenever  exudate  or  membrane  is  observed, 
a  culture  should  be  taken.  Redness  alone  suggests  simple  catarrhal 
pharyngitis,  or  scarlet  fever.  Eruptions  suggest  the  exanthemata. 
Exudate  suggests  follicular  tonsilitis,  but  is  sometimes  seen  in  scarlet 
fever  or  diphtheria.  Ulceration  suggests  Vincent's  angina,  s>T)hilis, 
or  tuberculosis.  Membrane  suggests  diphtheria,  scarlet  fever,  or 
membranous  angina. 

The  physician  should  note  whether  the  soft  palate  rises  properly 
when  the  child  gags;  failure  to  do  so  is  suggestive  of  diphtheritic  or 
bulbar  paralysis.  He  should  also  note  whether  the  uvula  is  elon- 
gated or  edematous. 

The  size  and  appearance  of  the  tonsils  should  be  carefully  noted. 
It  should  be  remembered  that  throughout  childhood  the  tonsils 
normally  are  relatively  larger  than  in  the  adult.  An  enlargement 
of  one  tonsil,  or  a  pushing  of  one  tonsil  toward  the  median  line,  is 
an  important  sign,  suggesting  tonsillar  or  peritonsillar  abscess.  En- 
largement of  both  tonsils  suggests  tonsillar  hypertrophy. 

The  posterior  wall  of  the  pharynx  is  inspected  for  the  swelhng 
characteristic  of  retropharyngeal  abscess,  for  the  enlargement  of  the 
lymph  foUicles  seen  in  chronic  catarrhal  inflammation,  and  for  the 
excessive  muco-purulent  or  purulent  secretion  seen  in  rhino-pharyn- 
gitis. It  must  be  remembered,  however,  that  retropharyngeal  ab- 
scess is  often  in\dsible  to  simple  inspection.  Therefore,  in  the  exami- 
tion  of  the  throat,  whenever  there  are  any  signs  of  obstruction  either  to 
respiration  or  to  deglutition,  a  digital  examijiation  should  be  made. 
A  gag  should  not  be  used,  as  in  retropharyngeal  abscess  the  wide 
separating  of  the  jaws  sometimes  results  in  sudden  death. 

The  Naso-pharynx. — The  naso-pharynx  cannot  be  examined  by 
ordinary  inspection.  Evidence  of  disease  in  this  region  is  obtained 
from  the  presence  of  pathological  secretion  coming  from  the  nose 
or  seen  in  the  throat,  and  from  evidences  of  obstruction  to  the  respi- 
ration. In  young  children,  the  naso-pharynx  cannot  be  examined 
with  the  mirror.  This  can  be  done  in  some  cases  in  children  old 
enough  to  cooperate,  but  in  many  cases  it  is  impossible  throughout 
childhood.  Consequently  the  physician  must  depend  on  digital  ex- 
amination. This  should  never  be  undertaken  as  part  of  a  routine 
examination,  but  should  be  carried  out  only  when  it  is  desired  to 
confirm  the  presence  of  adenoids,  or  when  there  are  signs  of  respi- 
ratory obstruction. 

For  digital  exploration  of  the  naso-pharynx,  the  child  is  held 
sitting  on  the  nurse's  lap,  with  its  left  side  against  her  body,  and 
its  arms  held  to  its  sides.  The  physician  stands  behind  the  child, 
and  with  his  left  hand  holds  the  mouth  open,  either  with  the  fore- 


Physical  Examination  83 

finger,  or  with  a  gag  if  the  child  be  too  large.  The  right  forefinger  is 
introduced  into  the  mouth  with  its  dorsum  downward.  In  reaching 
the  naso-pharynx,  care  must  be  taken  to  hook  the  finger  under  the 
soft  palate,  for  if  the  soft  palate  be  pushed  ahead  of  the  finger,  a 
very  false  impression  will  be  gained  from  palpation. 

The  Larynx. — Inspection  of  the  larynx  is  so  difficult  in  children, 
that  laryngoscopy  is  only  undertaken  in  special  cases.  Most  of  the 
common  diseased  conditions  in  the  larynx  can  be  recognized  by  the 
sound  of  the  respiration,  the  sound  of  the  voice,  and  the  character 
of  the  cough. 

The  E.ar. — Examination  of  the  ears  in  children  is  somewhat  dis- 
turbing, and  need  not  be  a  part  of  the  regular  routine  in  every  variety 
of  case.  When  a  satisfactory  explanation  of  the  symptoms  is  found 
elsewhere,  as  in  a  case  of  gastro-intestinal  or  nutritional  disorder 
without  fever,  there  is  no  necessity  of  examination  of  the  ears.  The 
ears,  however,  should  always  be  examined  as  a  routine  under  the 
following  circumstances:  (i)  When  there  is  fever,  or  when  there  are 
any  s}Tnptoms  which  could  be  caused  by  otitis,  which  are  not  ade- 
quately explained;  (2)  in  all  acute  infectious  diseases,  and  the  exami- 
nation should  be  frequently  repeated  in  the  course  of  the  disease; 
(3)  whenever  there  are  any  symptoms  suggesting  otitis  media.  It 
must  be  remembered  that  disease  of  the  middle  ear  in  childhood  exists 
more  often  without  symptoms  than  with  them,  and  cannot  be  ruled 
out  by  the  absence  of  such  symptoms  as  discharge,  pain,  putting  the 
hand  to  the  head,  restlessness,  mastoid  tenderness,  or  even  fever. 

The  ear  is  examined  with  a  head  mirror  and  a  speculum.  A  speci- 
ally small  speculum  is  needed  for  the  examination  of  an  infant's  ears. 
It  must  be  remembered  that  the  direction  of  the  external  auditory 
canal  is  difi'erent  in  infants,  and  that  to  straighten  the  canal  the  ear 
must  be  pulled  downward  and  a  little  forward,  instead  of  upward 
and  backward  as  in  older  children  and  adults. 

The  points  to  be  looked  for  are  reddening  of  the  drum,  bulging  of 
the  drum,  and  disappearance  of  the  landmarks.  The  drum  is  more 
horizontal  in  infancy  than  later. 

The  Neck. — Among  the  most  important  physical  signs  in  early 
life  are  rigidity  of  the  neck,  tenderness  of  the  back  of  the  neck,  and 
retraction  of  the  head.  Examination  with  reference  to  these  signs 
should  be  made  with  every  sick  child.  The  proper  method  for  the 
physician  is  to  place  both  hands — one  from  each  side — behind  the 
occipital  region  of  the  head.  The  head  is  tilted  forward  and  back 
for  rigidity,  and  then  the  physician  presses  on  the  back  of  the  neck 
for  tenderness.  Retraction  of  the  head  is  recognized  by  inspection. 
These  signs  are  by  no  means  diagnostic  of  meningitis,  but  suggest 
meningeal  irritation,  whether  from  infection  or  from  toxemia.     The 


84  Disease  in  Early  Life 

neck  should  also  be  examined  with  reference  to  torticollis,  spinal 
curvature,  venous  fulness,  abnormal  pulsation,  abnormal  swellings, 
and  enlargement  of  the  saHvary  glands,  thyroid,  or  lymph  nodes. 

Fig.  20 


Examination  for  rigidity  of  the  neck 

THE  CHEST.  Inspection. — The  chest  is  examined  with  refer- 
ence to  size,  shape,  symmetry,  mobility,  and  deformities.  The  nor- 
mal peculiarities  of  the  size  and  shape  of  the  chest  in  infants  and 
young  children  has  been  described  in  the  section  on  Normal  Develop- 
ment. The  most  common  deformities  of  the  chest  in  the  first  two 
years  of  life  are  due  to  rickets,  and  are  enumerated  under  the  descrip- 
tion of  that  disease.  The  physician  should  look  in  particular  for  the 
rachitic  rosary,  consisting  of  bead-like  enlargements  at  the  junc- 
tion of  the  ribs  with  their  cartilages.  Flattening  of  the  sides  of  the 
chest,  flaring  of  the  lower  ribs,  Harrison's  groove,  "pigeon  breast," 
"funnel  chest,"  should  all  be  looked  for.  The  last  is  more  often  a 
congenital  malformation  than  due  to  rickets.  Marked  deformity  of 
the  chest  in  infants  is  sometimes  produced  by  certain  less  common 
conditions.  I  have  seen  it  as  a  very  conspicuous  feature  of  con- 
genital pulmonary  atelectasis,  and  of  myatonia  congenita.  Deformity 
of  the  chest  in  older  children  is  caused  most  commonly  by  tuber- 
culosis of  the  spine,  disease   of    the   pleural  cavities,  and  paralysis 


Physical  Exla.mination  85 

or  weakness  of  the  muscles.  Prominence  of  the  region  of  the  sternum 
is  seen  in  forms  of  cardiac  disease  associated  with  marked  enlarge- 
ment of  the  heart.  The  amount  and  character  of  this  deformity  is 
valuable  as  evidence  as  to  the  period  in  life  when  the  cardiac  disease 
was  acquired.  In  congenital  cardiac  enlargement,  the  prominence 
is  most  marked  in  the  middle  of  the  sternum,  the  curve  receding  both 
above  and  below.  In  cardiac  disease  acquired  in  early  life,  the 
prominence  is  most  marked  over  the  lower  part  of  the  sternum. 
In  cardiac  enlargement  acquired  late  in  childhood,  there  is  usually 
no  precordial  prominence. 

Palpation. — The  rachitic  rosary  is  not  always  evident  to  in- 
spection, and  should  always  be  sought  by  palpation.  It  must  be 
remembered  that  in  thin  babies,  the  line  of  junction  of  the  ribs  with 
their  cartilages  is  palpable.  The  rosary  is  recognized  by  the  fact 
that  the  prominence  can  be  felt  at  the  sides  of  the  junction  as  well 
as  just  at  the  point  of  junction. 

THE  THYMUS. — The  normal  thymic  dulness  in  infancy  is  very 
difficult  to  detect.  Very  light  percussion  will  show  slight  dulness 
under  the  manubrium,  which  in  my  experience  is  continuous  with 
the  cardiac  dulness,  although  some  writers  state  that  there  is  a  zone 
of  vesicular  resonance  between.  The  thymic  dulness  is  said  to  dimi- 
nish gradually  and  to  disappear  at  about  six  years.  Practically, 
any  marked  degree  of  dulness  under  the  manubrium  should  suggest 
enlargement  of  the  thymus,  but  this  diagnosis  cannot  be  made  with 
any  certainty  on  routine  physical  examination.  The  thymus  may 
normally  extend  a  little  above  the  sternal  notch  but  is  not  palpable; 
if  it  is  felt  in  this  region,  it  is  certainly  enlarged. 

THE  HEART.  Inspection. — The  precordia  should  first  be  in- 
spected for  pulsation,  and  the  position  of  the  apex  beat  should  be 
noted.  It  must  be  remembered  that  in  early  infancy  the  cardiac 
impulse  is  normally  rarely  visible  and  is  often  not  palpable.  In 
childhood,  on  the  other  hand,  the  impulse  is  relatively  more  distinct 
than  in  the  adult.  The  physician  should  also  note  the  character  of 
the  impulse,  whether  localized  or  dift'use,  faint  or  forcible. 

Palpation. — The  evidence  obtained  by  inspection  as  to  the  car- 
diac impulse  should  be  confirmed  by  palpation.  In  placing  the 
position  of  the  apex  beat  (which  means  the  point  farthest  out  and 
down  in  which  the  impulse  is  visible  or  palpable),  the  physician 
should  remember  the  anatomical  conditions  characteristic  of  infancy 
and  early  childhood.  In  infancy,  the  apex  beat  is  normally  higher 
up  and  farther  out  than  in  later  life.  At  this  age  it  is  in  the  fourth 
interspace,  about  i  cm.  (3/8  in.)  outside  the  nipple  line.  From 
this  point  it  gradually  moves  inward  and  downward,  reaching  the 


86  Disease  in  Early  Life 

fifth  space  in  the  nipple  line  at  about  seven  years,  and  coming  inside 
the  nipple  line  before  the  thirteenth  year  For  purposes  of  record, 
it  is  best  to  record  the  position  of  the  apex  in  relation  to  the  nipple 
line,  rather  than  to  the  median  line,  because  the  distance  from  the 
median  line  varies  with  the  size  of  the  child. 

The  physician  should  also  confirm  by  palpation  his  observations 
as  to  the  force  and  character  of  the  cardiac  impulse,  and  should 
note  whether  any  thrill  be  present. 

Percussion. — The  outlines  of  the  cardiac  dulness  are  now  deter- 
mined by  percussion.  The  normal  outlines  at  the  various  ages  of 
infancy  and  childhood  have  been  given  in  the  section  on  Normal 
Development.  Both  the  superficial  or  absolute  dulness,  and  the  deep 
or  relative  dulness,  should  be  noted.  Many  authorities  state  that 
the  absolute  dulness  is  more  difficult  to  determine  than  is  the  relative 
dulness.  In  my  experience,  it  is  just  the  other  way;  the  absolute 
dulness  is  easier  to  determine,  but  is  less  reliable  as  evidence  of  the 
actual  size  of  the  heart  than  is  the  relative  dulness.  It  is  for  this 
reason  that  it  is  better  to  record  both  outlines. 

Percussion  in  infants  and  young  children  should  be  light  and 
delicate.  In  determining  the  left  border,  the  physician  should  place 
his  finger  first  on  the  area  between  the  left  nipple  and  the  left  border 
of  the  sternum,  and  should  percuss  toward  the  left  until  the  tone 
becomes  resonant.  In  determining  the  boundary  of  absolute  dulness 
on  the  right,  he  should  begin  at  the  same  point  and  percuss  toward 
the  right  until  there  is  a  change  of  tone.  In  determining  the  boun- 
dary of  relative  dulness  on  the  right,  the  physician  should  begin 
percussion  entirely  to  the  right  of  the  cardiac  area,  and  should  per- 
cuss toward  the  left  until  a  modification  of  the  resonance  is  noted. 
In  determining  the  upper  border  of  dulness,  he  should  percuss  from 
above  downward. 

Auscultation. — In  children,  auscultation  should  be  performed  as 
in  the  adult,  the  most  significant  areas  being  those  of  the  apex  beat, 
the  middle  of  the  precordia  near  the  left  border  of  the  sternum, 
the  base  on  each  side  of  the  sternum,  and  the  lower  part  of  the  ster- 
num itself.  The  character  of  the  heart  sound  should  be  noticed  with 
reference  to  rate,  rhythm,  tone,  loudness,  and  relative  accentuation 
or  diminution  in  the  different  areas.  A  peculiar  character  of  the 
first  sound,  which  lacks  the  booming  quality  of  later  life,  and  resembles 
the  second  sound,  is  normal  in  early  infancy  and  should  be  remem- 
bered. It  should  also  be  remembered  that  in  infancy  and  early 
childhood,  the  first  heart  sound  is  fainter  at  the  base  than  in  later  fife. 

The  pulmonic  second  sound  is  normally  louder  than  the  aortic 
throughout  the  whole  of  childhood,  and  for  this  reason  accentuation 
of  the  second  pulmonic  sound  is  difficult  to  recognize,  and  not  of 


Fig.  21 — Xormal  areas  of  dulness  to  percussion  of  the  front  of  the  chest 

A.  Hepatic  dulness 

B.  Superficial  or  absolute  cardiac  dulness 

C.  Deep  or  relative  cardiac  dulness 
Thymic  dulness  in  an  infant 


Physical  Examination  87 

much  diagnostic  significance.  Reduplication  of  the  second  sound 
is  also  often  heard  in  normal  children,  and  should  not  be  considered 
pathological  unless  there  are  other  evidences  of  cardiac  disease. 

The  presence  of  such  adventitious  sounds  as  murmurs  and  friction- 
rubs  should  be  carefully  noted.  With  reference  to  murmurs  the 
following  points  should  be  recorded:  (i)  The  region  in  which  they 
are  heard  and  their  point  of  greatest  intensity;  (2)  their  time  with 
reference  to  the  cardiac  cycle  —  systolic,  presystolic,  or  diastolic;  (3) 
their  loudness;  (4)  their  character — soft,  harsh,  or  musical;  (5)  their 
transmission — whether  they  are  heard  in  the  axilla,  back,  or  over 
the  vessels  of  the  neck;  (6)  whether  or  not  they  replace  the  heart 
sounds.  It  is  to  be  remembered  that  in  the  first  two  or  three  years 
of  life,  murmurs  clue  to  acc|uired  cardiac  disease  are  very  uncommon. 
At  this  age,  murmurs  are  either  functional,  or  represent  a  congenital 
cardiac  lesion.  The  physician  in  considering  the  relative  weight  of 
evidence  pointing  toward  the  functional  or  organic  origin  of  a  murmur, 
should  remember  that  in  an  infant,  if  the  evidence  points  toward  organic 
disease,  the  lesion  is  usually  congenital.  The  significance  of  murmurs 
will  be  considered  in  detail  in  the  division  on  Diseases  of  the  Heart. 

LUNGS.  Inspection. — The  observations  as  to  the  rate  and  char- 
acter of  the  respiration,  and  as  to  the  presence  or  absence  of  cough, 
have  been  made  during  the  general  preliminary  examination  of  the 
body.  The  ph3^sician  should  therefore  note  whether  the  movement 
of  the  chest  on  both  sides  is  equal,  whether  there  is  inspiratory 
retraction  of  the  intercostal  spaces,  and  whether  there  is  increased 
circumference  of  one  side  with  bulging  of  the  intercostal  spaces. 

Palpation. — Palpation  over  the  lungs  is  used  to  deterrnine  whether 
there  is  increase  or  diminution  in  the  tactile  fremitus  caused  by  the 
voice  sounds.  This  is  much  less  useful  in  children  than  in  adults^ 
because  in  many  cases  it  can  only  be  obtained  when  the  child  is 
crying,  and  the  crying  voice  sounds  are  so  loud,  and  the  chest  wall 
so  thin,  that  the  finer  differences  cannot  be  detected.  It  is  also  less 
valuable  in  diagnosis,  especially  in  young  children,  as  good  tactile 
fremitus  is  often  felt  over  an  effusion.  In  older  children,  who  are 
able  to  speak  as  ordered  by  the  physician,  the  results  of  palpation 
are  more  valuable.  The  tactile  fremitus  should  always  be  tested, 
but  the  physician  should  not  rely  too  much  on  its  results  in  young 
children,  as  compared  with  the  results  of  other  methods  of  examina- 
tion.    Rales  are  often  palpable  in  young  children. 

Percussion. — It  is  more  difficult  in  infancy  and  early  childhood 
to  recognize  changes  in  the  percussion  note,  than  in  later  childhood. 
When  a  young  child  is  crying  hard,  the  resonance  of  all  parts  of 
the  lungs  is  impaired.  When,  however,  a  clear  difference  in  the 
resonance  of  the  two  sides  is  made  out,  the  evidence  is  just  as  valu- 


Disease  in  Early  Life 


able  as  it  is  in  later  childhood,  unless  the  only  abnormality  found  is 
slight  dulness  over  the  right  base.  This  may  be  due  to  the  relatively 
large  size  of  the  Uver  in  infants.  Percussion  in  children  should  be 
particularly  light  and  deHcate,  on  account  of  the  thinness  of  the 
chest  wall,  and  the  small  size  of  the  parts.  Strong  percussion  will 
produce  confusing  sounds  coming  from  a  distance,  and  cannot  elicit 
a  slight  relative  dulness.  The  finger,  not  a  percussion  hammer, 
should  always  be  used.  The  results  of  percussion  are  entirely  un- 
reliable if  an  infant  is  lying  on  its  side,  because  the  chest  is  so  com- 
pressible that  the  resonance  of  the  lower  lung  is  perceptibly  impaired. 
The  infant  may,  however,  be  lying  on  its  back,  or  on  its  face,  may 
be  sitting  upright,  or  may  be  held  upright  facing  the  shoulder  of 

Fig.  22 


Percussion  of  the  front  of  the  chest 

the  mother.  Even  in  the  latter  case,  there  is  some  possibihty  of 
compression,  and  the  infant  should  be  transferred  to  the  other  shoulder 
if  there  is  any  suspicion  of  dulness  on  one  side;  also,  if  possible,  the 
arms  should  be  placed  in  approximately  the  same  position. 

It  is  difficult  in  young  children  to  determine  accurately  the  borders 
of  the  lungs,  and  usually  impossible  to  determine  by  percussion  the 
mobility  of  the  pulmonary  borders.  The  borders  in  infancy  are 
about  one  space  higher  than  in  later  life.  The  relation  of  the  various 
lobes  of  the  lung  to  the  chest  wall  is  practically  the  sam.e  in  infancy 


Fig.  23— Boundaries  of  the  lobes  of  the  lungs  from  in  front 


Physical  Examination 


89 


and  childhood  as  in  adult  Ufe.  The  lines  between  the  upper  and 
lower  lobes  start  from  the  vertebrae  at  the  level  of  the  spines  of  the 
scapulae,  pass  through  the  mid-axillary  lines  at  the  level  of  the  fourth 
rib,  and  reach  the  borders  of  the  lung  at  the  sixth  rib,  in  the  nipple 
line  on  the  left,  in  the  parasternal  line  on  the  right.  The  boundary 
between  the  upper  and  middle  lobes  starts  on  the  right  at  the  fourth 
costal  cartilage,  runs  into  the  axilla,  where  it  is  close  above  the  line 
separating  the  upper  and  lower  lobes,  and  reaches  this  line  at  the 
outer  border  of  the  scapula. 

Fig.  24 


Boundaries  of  the  lobes  of  the  lungs  from  behind 

The  principal  points  to  be  noted  are  relative  dulness,  flatness, 
hyperresonance,  and  tympany.  It  is  useful  to  remember  the  follow- 
ing points  characteristic  of  infancy  and  childhood:  i.  The  percussion 
note  is  normally  more  resonant  than  in  adults,  except  in  a  crying 
infant  2.  The  note  at  the  left  base  is  more  tympanitic  because  of 
the  proximity  of  the  stomach,  and  this  tympany  may  be  very  marked 
when  the  stomach  is  distended  with  gas.  3  The  percussion  note  is 
not  higher  pitched  over  the  right  apex,  as  in  adult  life.  4.  Up  to 
about  ten  years  of  age,  there  is  slight  dulness  under  he  inner  third 
of  the  left  clavicle;  this  is  very  difficult  to  elicit  in  infancy 

It  is  very  important  in  early  life  to  distinguish  between  dulness 
and  flatness  on  percussion,  and  this  is  one  of  the  most  important 
differentiating  signs  between  pu'monary  consolidation,  and  pleuritic 


90 


Disease  in  Early  Life 


effusion.  Light  percussion  must  be  used,  because  the  layer  of  fluid 
in  children  is  very  thin,  and  heavy  percussion  will  obtain  some  pul- 
monary resonance,  even  though  fluid  be  present. 

More  important  often  than  the  sound  obtained  by  percussion,  is 
the  sense  of  resistance.  This  can  also  be  elicited  by  tapping  directly 
on  the  chest  wall  with  the  tips  of  the  fingers,  and  this  method  of 
examination  should  not  be  neglected.  It  is  particularly  valuable  in 
infancy,  at  which  age  an  increased  sense  of  resistance  is  an  important 
diagnostic  sign  of  fluid  in  the  pleural  cavity. 

Fig.  2i, 


Percussion  of  the  back  of  the  chest 


Auscultation. — The  features  to  be  noted  on  auscultation  in 
children  as  in  adults  are,  the  character  of  the  respiratory  murmur, 
the  vocal  resonance,  and  the  presence  or  absence  of  adventitious 
sounds  The  standard  by  which  abnormality  is  recognized  is,  how- 
ever, so  different  in  infancy  and  childhood  from  that  of  adult  life, 
that  there  is  no  part  of  the  physical  examination  which  so  greatly 
requires  the  special  knowledge  and  training  of  the  pediatrist,  as  the 
auscultation  of  the  lungs.  The  pecuHarities  are  most  marked  in 
infancy,  and  grow  progressively  less  marked  throughout  childhood. 
In  children  approaching  the  age  of  puberty,  the  adult  standard  has 
been  reached.  The  normal  pecuHarities  encountered  in  the  auscul- 
tation of  infants  and  children,  are  due  to  peculiarities  of  anatomical 


Physical  Examination 


91 


development.  The  principal  causes  are,  the  shallowness  of  respira- 
tion in  early  life,  and  the  greater  proportion  of  bronchial  air  space 
to  alveolar  air  space  in  the  lungs. 

The  respiratory  murmur  in  infants  and  young  children  is  higher 
pitched  and  harsher  than  in  the  adult.  If  pitch  be  taken  as  one  of 
the  criteria  by  which  bronchial  respiration  is  recognized,  the  normal 
respiratory  sound  of  the  young  child  approaches  the  bronchial.  But 
the  criteria  used  in  recognizing  bronchial  respiration  in^the  adult, 


Fig.  26 


Percussion  of  the  apex  of  the  lungs 

should  not  be  used  in  childhood,  and  should  be  entirely  banished 
from  the  mind  of  the  physician  when  he  is  examining  a  sick  child. 
Unless  he  does  this,  the  harsh,  high  pitched  respiratory  murmur  of 
early  life,  which  is  called  puerile,  will  often  be  mistaken  for  bronchial 
respiration.  The  recognition  of  bronchial  respiration  in  children 
depends  in  no  way  upon  loudness,  harshness,  or  pitch.  It  differs  from 
vesicular  respiration  only  in  the  character  of  the  sound,  and  in  the 
greater  length  of  expiration.  Unfortunately,  the  latter  feature  can- 
not always  be  recognized.  The  expiration  is  frequently  replaced  by 
the  cry;  sometimes  in  young  infants  it  cannot  be  heard  because  the 
child  is  breathing  very  quietly,  and  when  an  attempt  is  made  to 
cause  it  to  draw  a  longer  breath,  it  begins  to  cry,  and  only  inspira- 
tion is  audible.     Prolonged  expiration  is  a  valuable  sign  of  bronchial 


92  Disease  in  Early  Life 

breathing  when  found,  but  it  is  so  often  not  found,  that  the  physician 
must  accustom  himself  to  recognizing  bronchial  breathing  mainly  by 
the  character  of  the  sound  which  is  heard  on  inspiration  as  well  as. 
on  expiration.  The  character  of  the  sound  in  the  bronchial  breath- 
ing of  childhood  must  be  learned  mainly  by  experience.  It  is  diffi- 
cult to  describe.  It  is  high  pitched,  but  so  is  puerile  breathing.  It 
is  decidedly  not  harsh  as  compared  with  normal  puerile  breathing. 
It  can  best  be  described  as  having  a  peculiar  nasal  quality,  and  as 
sounding  close  to  the  ear  as  if  it  came  from  some  point  intermediate 
between  the  ears  of  the  physician  and  the  bell  of  the  stethoscope. 
It  should  be  remembered  that  when  the  character  of  the  respiration 
is  the  same  on  both  sides  of  the  chest,  front  and  back,  it  cannot  be 
bronchial.  In  case  of  doubt,  the  physician  should  listen  to  the 
respiratory  murmur  over  the  second  dorsal  spine  of  the  vertebrae. 
In  this  situation,  the  breathing  is  normally  purely  bronchial,  and 
gives  a  good  standard  for  comparison  as  to  the  quality  of  the  sounds 
heard  in  other  parts  of  the  chest. 

The  term  "increased"  is  sometimes  applied  to  the  respiratory 
murmur  as  heard  in  adults,  the  meaning  being  increase  in  the  loud- 
ness, or  intensity  of  the  sound.  This  term  should  never  be  applied 
to  the  description  of  the  respiratory  murmur  heard  in  childhood. 
There  is  no  limit  to  the  loudness  or  intensity  of  the  sound  normally 
heard.  When  there  is  a  difference  in  the  loudness  of  the  respiratory 
murmur  in  the  corresponding  areas  of  the  two  sides  of  the  chest,  in 
the  vast  majority  of  cases  in  childhood,  the  louder  side  represents  a 
normal  condition,  while  the  fainter  side  is  evidence  of  a  pathological 
condition.  Occasionally,  especially  in  older  children,  the  bronchial 
breathing  heard  over  the  consolidation  is  louder  than  the  normal 
breathing  heard  on  the  other  side.  In  such  a  case  the  breathing 
might  be  called  relatively  increased,  but  its  bronchial  character  is 
always  plainly  apparent.  A  relative  increase  in  loudness  alone, 
should  never  be  considered  abnormal.  It  is  not  uncommon  for 
physicians  or  students  unaccustomed  to  the  examination  of  children, 
to  diagnose  lobar  pneumonia  on  the  wrong  side.  The  breathing  over 
a  consolidation  in  children  is  frequently  so  diminished  in  loudness 
that  its  bronchial  character  is  not  recognized,  especially  if  the  child 
is  breathing  quietly;  and  the  loud,  harsh,  puerile  breathing  on  the 
normal  side  is  mistaken  for  bronchial  breathing.  Whenever  the 
respiratory  sound  in  infancy  is  so  feeble  that  its  character  cannot 
be  determined,  the  baby  must  be  made  to  cry  and  thus  take  a  long 
-breath.  The  baby  should  never  be  examined  when  lying  on  its 
side,  because  in  this  position  the  compression  of  the  chest  will  lead 
to  a  diminution  of  the  respiratory  murmur  on  the  lower  side. 

It  should  be  remembered  that  bronchial  respiration  is  normally  heard 
over  a  greater  area  at  the  root  of  the  lungs  in  infancy  and  early  child- 


Physical  Examination  93 

hood  than  in  later  childhood  and  adult  life.     The  slightly  prolonged 
expiration  heard  at  the  right  apex  in  adults  is  not  found  in  children. 

The  Vocal  TIesonance,  like  the  tactile  fremitus,  is  not  so  valu- 
able as  diagnostic  evidence  in  childhood  as  it  is  in  adult  life.  Chil- 
dren cannot  usually  be  made  to  say  "one,  two,  three,"  or  "ninety- 
nine,"  as  can  adults,  and  vocal  resonance  can  only  be  obtained  when 
they  are  crying.  The  child's  cry  is  so  loud,  and  the  chest  walls  are 
so  thin,  that  the  sound  heard  on  auscultation  is  often  too  overpower- 
ing for  an  estimate  of  its  character  and  intensity.  A  pronounced 
degree  of  bronchophany  can  usually  be  heard,  even  when  the  child 
is  crying.  Diminution  in  the  vocal  resonance  is  not  only  more 
difficult  to  detect  in  young  children,  but  is  less  constant  as  a  sign 
of  pleuritic  effusion,  and  is  often  present  over  consolidation  when 
there  is  no  fluid.  In  older  children  the  value  of  the  vocal  resonance 
approaches  that  of  adults.  In  some  cases,  however,  even  in  infants, 
a  change  in  the  voice  sounds  on  one  side  can  be  recognized  before 
any  change  in  the  character  of  the  respiration. 

Rales  have  the  same  character,  varieties,  and  significance  in 
children  as  in  adults,  and  require  no  detailed  description.  They 
are  often  louder  in  infancy  than  in  adults.  One  error  frequently 
made  in  the  examination  of  the  lungs  of  infants  and  young  children, 
is  the  mistaking  of  rales  originating  in  the  nose  or  naso-pharynx  for 
true  bronchial  rales.  The  former  are  frequently  transmitted  to  the 
chest,  but  should  easily  be  distinguished  from  rales  coming  from 
the  lungs.  Bronchial  rales  are  never  exactly  alike  over  both  lungs, 
and  are  not  heard  over  the  trachea  or  cheeks,  whereas  rales  made 
in  the  upper  air  passages  have  the  same  sound  over  both  lungs,  the 
trachea,  and  the  cheeks. 

Pleural  Friction  Sounds  are  very  rarely  heard  in  infancy, 
although  pleurisy  is  not  uncommon  at  this  age.  The  reason  for  this 
is  unknown.  In  childhood  they  have  the  same  significance  as  in 
adults,  but  in  my  experience,  are  somewhat  less  commonly  heard. 

THE  ABDOMEN.  Inspection.— The  abdomen  should  be  in- 
spected with  reference  to  size,  prominence,  retraction,  shape,  irregu- 
larities of  outhne,  tension  of  the  wall,  the  condition  of  the  umbilicus, 
herniae,  superficial  veins,  respiratory  movements,  epigastric  pulsa- 
tion, and  visible  peristalsis.  The  normal  appearance  of  the  abdomen 
at  the  various  ages  has  been  described  in  the  section  on  Normal 
Development. 

Enlargement  of  the  abdomen  is  very  common  in  infancy.  The 
most  common  cause  is  various  disturbances  of  digestion  and  nutri- 
tion, which  act  in  two  ways  in  producing  abdominal  enlargement. 
Disturbed  digestion  may  produce  an  increased  formation  of  gas  in 
the  intestine.     Enlargement  of  the  abdomen  from  this  cause  is  seen 


94  Disease  in  Early  Life 

also  in  older  children  in  chronic  indigestion  from  an  excess  of  carbo- 
hydrate, the  abdomen  being  enlarged  chiefly  in  the  upper  portion. 
In  disturbances  of  nutrition  the  walls  of  the  intestines  suffer  with 
the  rest  of  the  tissues  and  become  relaxed,  so  that  even  without 
increased  formation  of  gaB  there  may  be  increased  accumulation  of 
gas.  The  enlargement  of  the  abdomen  seen  in  rickets  and  in  most 
chronic  digestive  disturbances,  is  produced  in  this  latter  way. 

In  older  children  enlargement  of  the  abdomen  is  suggestive  of 
some  more  serious  condition,  and  the  possibility  of  the  same  condi- 
tions in  infancy  must  not  be  forgotten.  Among  these  causes  are 
ascites,  tuberculous  peritonitis,  enlargement  of  the  liver  or  spleen, 
sarcoma  of  the  kidney,  and  congenital  dilatation  of  the  colon.  Irregu- 
larities in  outline  are  suggestive  of  enlargement  of  one  of  the  solid 
viscera,  or  sarcoma  of  the  kidney.  A  prominence  in  the  lower  por- 
tion in  an  infant  may  be  due  to  a  distended  bladder. 

Retraction  of  the  abdomen  is  usually  due  to  lack  of  intestinal  con- 
tents, both  gaseous  and  fluid.  It  is  often  seen  in  acute  diarrheas,  in 
meningitis,  and  in  conditions  characterized  by  severe  vomiting,  such 
as  acidosis.     It  is  never  due  in  children  to  hysteria  or  lead  poisoning. 

Distention  of  the  abdomen  is  due  to  the  same  causes  as  enlarge- 
ment, representing  only  a  greater  degree. 

Inspection  of  the  umbiHcus  is  particularly  important  in  the  new- 
born. Umbilical  herniae  are  easily  recognized.  Epigastric  herniae 
are  not  very  rare  in  infants  and  young  children. 

Visible  peristalsis  is  a  very  important  diagnostic  sign  in  infancy. 
When  over  the  epigastrium  it  is  suggestive  of  pyloric  stenosis.  Over 
other  parts  of  the  abdomen,  it  is  suggestive  of  tuberculosis  or  intes- 
tinal obstruction. 

Palpation. — In  the  general  palpation  of  the  abdomen,  the  points 
to  be  noted  are  the  tension  and  resistance  of  the  walls,  and  the  pres- 
ence or  absence  of  spasm  of  the  muscles,  tenderness,  fluctuation,  and 
abnormal  solid  bodies.  Spasm  and  resistance  must  be  localized,  and 
it  must  be  determined  whether  they  are  voluntary  or  involuntary. 
If  tenderness  be  present,  its  seat  must  be  noted,  and  whether  it  is 
superficial  or  deep.  Abdominal  tenderness  is  a  less  common  sign 
in  childhood  than  in  adult  life,  and  is  not  often  seen  in  disturbances 
of  the  stomach  or  intestine.  It  should  always  suggest  the  possi- 
bility of  some  serious  condition,  such  as  appendicitis,  peritonitis,  or 
intussusception.  A  sense  of  fluctuation  is  often  obtained  in  infants 
and  young  children  due  to  the  liquid  character  of  the  intestinal  con- 
tents, which  may  be  mistaken  for  ascites.  The  fluid  wave  of  ascites 
is  obtained  as  in  the  adult,  and  has  the  same  diagnostic  significance. 
It  is  often  difficult  to  teh  whether  masses  felt  in  the  abdomen  are 
fecal  accumulations,  or  the  masses  of  tuberculous  peritonitis,  and  it 


Physical  Examination  95 

is  sometimes  necessary  to  repeat  the  examination  after  the  bowels 
have  been  emptied,  in  order  to  clear  up  this  point. 

Percussion  of  the  abdomen  is  employed  mainly  to  determine  the 
presence  of  fluid,  to  determine  the  character  of  masses  felt,  and  to 
map  out  the  outlines  of  the  abdominal  organs.  The  sign  of  free 
fluid  is  dulness  in  the  flanks,  shifting  with  change  of  position.  Care 
must  be  taken  in  interpreting  this  sign,  as  in  infants  and  young 
children  the  liquid  feces  tend  to  gravitate  to  the  flanks,  and  will 
give  a  dulness  which  shifts  with  change  of  position.  Very  marked 
shifting  dulness,  or  a  fluid  wave  is  necessary  for  a  conclusive  diag- 
nosis of  ascites. 

The  Stomach. — Percussion  of  the  stomach  is  difflcult  in  infancy 
and  childhood,  and  the  results  obtained  are  unreliable.  A  dilated 
stomach,  when  distended  with  gas,  can  sometimes  be  recognized 
both  by  inspection  and  percussion.  Visible  peristalsis  is  an  import- 
ant sign  of  pyloric  stenosis. 

The  Liver  is  investigated  by  palpation  and  percussion.  The 
upper  border  must  be  determined  by  percussion.  The  lower  border 
in  infants  and  young  children  is  best  determined  by  palpation,  as 
percussion  is  unreliable  on  account  of  the  thinness  of  the  edge.  The 
upper  border  of  the  liver  flatness  is  at  the  fifth  rib  in  the  right  nipple 
line  in  infancy.  From  this  point  it  gradually  descends,  the  adult 
position  being  reached  at  about  six  years.  The  lower  border  in 
infancy  may  normally  extend  3  cm.  (1-1/8  in.)  below  the  costal 
border  in  the  mammihary  line,  and  6  cm.  (2-1/4  ^^•)  below  the  tip 
of  the  ensiform.  It  is  palpable  in  the  mammillary  line  up  to  three 
years,  and  may  sometimes  be  felt  after  this  time  in  children  with 
relaxed  abdominal  walls  if  the  fingers  are  pushed  up  under  the  costal 
border.  The  liver  in  early  childhood  is  easy  to  feel  on  account  of 
the  thinness  of  the  abdominal  waU.  It  is,  however,  very  often 
missed,  because  the  physician,  not  realizing  how  soft  and  thin  is 
the  edge,  and  how  superficially  it  lies,  palpates  too  deeply  and 
forcibly. 

The  liver  is  examined  for  enlargement,  tenderness,  and  irregu- 
larity of  outline.  Examination  of  the  gall-bladder  is  unsatisfac- 
tory in  early  Hfe,  but  is  hardly  necessary,  as  this  organ  is  very  rarely 
diseased  in  childhood. 

The  Spleen. — Percussion  of  the  spleen  is  so  difficult  in  early 
life,  on  account  of  the  small  size  of  the  organ,  that  it  is  hardly  worth 
while  to  undertake  it.  The  outHne  may  be  determined  in  older 
children,  but  palpation  of  the  spleen  is  so  easy  in  infancy  and  child- 
hood that  it  is  better  to  trust  to  this  method  of  examination. 

The  spleen  should  be  palpated  with  the  physician  on  the  right 
side  of  the  patient.     Many  text-books  recommend  palpation  of  the 


96  Disease  in  Early  Life 

spleen  from  the  left  side,  with  the  tips  of  the  curved  fingers.  In 
my  experience  palpation  from  the  right  is  infinitely  better.  The 
right  hand  should  be  placed  almost  flat  upon  the  abdomen,  with  the 
fingers  almost  straight.  In  the  child  the  abdomen  wall  is  so  thin, 
and  the  spleen  is  so  superficial,  that  care  must  be  taken  not  to  pal- 
pate too  deeply,  for  the  spleen  may  thus  be  pushed  down  with  the 
abdominal  wall  without  being  detected.  The  extreme  tips  of  the 
fingers  should  be  placed  against  the  costal  border,  and  then  are  lightly 
and  quickly  depressed.  By  repeating  this  operation,  drawing  the 
hand  forward  and  back,  the  spleen  will  not  be  missed  if  palpable. 
The  proper  position  for  the  hand  is  shown  in  the  illustration. 

The  spleen  is  normally  not  palpable  at  any  age,  except  that  in 
infants  with  lax  abdominal  walh,  the  normal  spleen  can  sometimes 
be  felt  if  the  fingers  are  pushed  up  under  the  costal  border.  When- 
ever the  spleen  is  palpable  below  the  costal  border,  it  is  safe  to  con- 
clude that  it  is  enlarged.  When  there  is  marked  splenic  enlargement, 
forming  a  large  mass  on  the  left  side  of  the  abdomen,  it  is  easier  in 
the  child  than  in  the  adult  to  recognize  the  mass  as  spleen,  on 
account  of  its  very  superficial  position,  and  flatness  on  percussion; 
moreover,  the  notch  can  usually  be  clearly  felt. 

The  Kidneys. — The  outHne  of  the  normal  kidneys  cannot  be 
percussed  either  in  infancy  or  in  childhood.  The  normal  kidney 
can  only  rarely  be  palpated  even  when  the  abdominal  walls  are 
very  thin  and  lax.  If  the  kidney  is  palpable,  it  can  be  concluded 
that  it  is  enlarged  or  displaced.  Floating  kidneys  are  very  rare 
in  infancy  and  childhood,  and  if  present,  usually  represent  a  congen- 
ital abnormality  Palpable  masses  in  the  region  of  the  kidney  usually 
represent  tumors,  the  most  common  being  sarcoma.  Congenital 
cystic  kidney,  and  pyelo-nephrosis  are  seen  at  times.  Tumors  of 
the  kidney  are  recognized  by  the  fact  that  they  do  not  move  with 
respiration,  and  usually  show  some  tympany  on  percussion,  as  the 
colon  lies  in  front  of  them. 

Tenderness  on  deep  palpation  in  the  region  of  the  kidney  is  some- 
times seen  in  pyehtis.  It  should  suggest  either  pyehtis  or  peri- 
nephritic  inflammation. 

The  Bladder. — In  infancy  the  small  oblique  pelvis  is  almost 
wholly  filled  by  the  rectum,  and  consequently  almost  all  of  the 
bladder  lies  in  the  abdominal  cavity  above  the  crest  of  the  pubes. 
Distention  of  the  bladder  forms  a  rounded  tumor  in  the  lower  part 
of  the  abdomen,  which  lies  close  to  the  abdominal  wall,  and  may 
even  reach  to  the  umbilicus.  Most  of  the  anterior  surface  is  un- 
covered by  peritoneum.  After  the  child  gets  upon  its  feet,  the 
weight  of  the  urine  and  the  anatomical  changes  in  the  shape  of  the 


^ 


». 


\ 


Physical  Examination  97 

pelvis  gradually  cause  the  bladder  to  assume  the  adult  position,  which 
is  reached  in  middle  childhood. 

This  high  position  of  the  bladder  in  infancy  and  early  childhood 
has  caused  many  bad  mistakes  in  diagnosis.  A  distended  bladder 
has  often  been  mistaken  for  ascites,  or  a  new  growth.  Whenever 
there  is  any  question  of  these  conditions,  the  bladder  should  always 
be  emptied  by  catheterization. 

In  connection  with  the  examination  of  the  bladder,  the  groins 
should  be  carefully  examined.  AbnormaHties  to  be  looked  for  are 
hernia,  hydrocele  of  the  cord,  undescended  testicles  or  misplaced 
ovary,  and  enlargement  of  the  lymph  nodes. 

The  External  Genitals. — Inspection  of  the  external  genitals 
should  always  form  a  part  of  the  physical  examination,  particularly 
in  females,  and  in  the  newborn.  The  principal  abnormalities  to  be 
looked  for  are  malformations  and  discharge.  The  commonest  mal- 
formation in  females  is  adhesions  of  the  nymphae.  The  prepuce  is 
normally  adherent  to  the  cHtoris  throughout  infancy  and  early  child- 
hood. In  males  the  physician  should  look  for  phimosis,  undescended 
testicles,  and  hydrocele.  In  infants  the  glans  penis  is  normally 
covered  by  the  prepuce,  which  is  adherent.  In  phimosis  the  pre- 
puce is  so  narrowed  that  it  cannot  be  retracted.  The  testicles  may 
be  wholly  or  partially  undescended.  Tumors  of  the  testes,  varico- 
cele, balanitis,  ulcerations,  and  urethral  discharge  (in  the  male), 
are  rare  in  children.  In  the  female,  vulvo-vaginitis  is  fairly  common. 
It  is  often  of  gonorrhoeal  origin,  but  may  be  due  to  uncleanliness 
or  some  other  source  of  irritation.  Whenever  there  is  the  least  sign 
of  discharge,  a  bacteriological  examination  should  be  made. 

The  Anus. — The  buttocks  should  always  be  retracted  and  the 
anus  inspected,  particularly  in  infants.  The  condition  of  the  skin 
about  the  anus  should  be  noted.  Fissures  of  the  anus  are  not  un- 
common in  infancy.  Hemorrhoids  are  uncommon  in  childhood  as 
compared  with  adult  Hfe.  Prolapse  of  the  rectum,  on  the  other 
hand,  is  common.  Ulcers,  condylomata,  and  mucous  patches  are 
often  found  about  the  anus  in  syphilitic  infants.  Fistula,  ischio- 
rectal abscess,  and  pilonidal  sinus  are  seen  at  times. 

The  Rectum. — A  rectal  examination  is  not  necessary  unless  there 
is  something  in  the  history  suggesting  its  advisability.  Whenever 
there  is  any  question  of  intestinal  obstruction,  intussusception,  or 
any  obscure  condition  in  the  abdominal  cavity,  a  rectal  examina- 
tion should  be  made. 

THE  EXTREMITIES.— In  examining  the  extremities  the  physi- 
cian should  keep  the  following  points  in  mind :    Relative  size,  position, 
deformities,  the  shafts  of  the  long  bones,  the  joints,  spasm,  and  paralysis. 
7 


98  Disease  in  Early  Life 

Relative  Size. — The  limbs  are  normally  alike  in  circumference 
on  the  two  sides.  A  difference  is  more  apt  to  be  due  to  atrophy  on 
one  side  than  to  hypertrophy  on  the  other.  If  any  apparent  differ- 
ence be  present,  it  should  be  confirmed  by  measurement.  Care  must 
be  taken  that  measurements  are  made  in  exactly  the  same  place. 
Differences  of  less  than  i  cm.  are  within  the  limits  of  error  in  measure- 
ment, and  should  be  disregarded. 

It  is  also  important  to  determine  whether  the  legs  are  of  equal 
length.  This  can  only  be  determined  with  the  child  lying  on  its 
back.  A  difference  may  be  an  actual  difference  in  length,  or  due 
to  congenital  dislocation  of  the  hip.  The  latter  is  recognized  by  the 
high  position  of  the  trochanter. 

Position. — Abnormal  positions  of  the  extremities  are  usually  due 
either  to  temporary  muscular  spasm  or  to  permanent  muscular  con- 
tractures. The  details  of  the  examination  for  spasm  will  be  de- 
scribed under  the  examination  of  the  nervous  system. 

A  limb  is  sometimes  held  in  an  abnormal  position  without  spasm, 
the  cause  being  some  painful  lesion  which  is  more  comfortable  when 
the  limb  is  held  in  this  way.     The  most  common  cause  is  arthritis. 

Deformities  — Deformities  of  the  extremities  are  either  congen- 
ital or  acquired.  The  former  variety  includes  such  conditions  as 
club-foot,  club-fingers,  web-fingers,  congenital  dislocation  of  the  hip, 
and  a  variety  of  rare  gross  malformations. 

The  most  common  acquired  deformities  are  due  to  rickets,  and 
are  enumerated  in  detail  under  the  description  of  that  disease.  There 
is  a  sabre-like  deformity  of  the  tibiae  which  is  especially  character- 
istic of  late  syphilis  in  childhood.  It  is  often  mistaken  for  a  rachitic 
deformity,  but  occurs  later  in  childhood.  The  limbs  are  also  deformed 
in  cretinism  and  chondrodystrophy  fetalis. 

Contractures  from  disease  of  the  nervous  system  may  cause  a 
condition  which  is  more  than  an  abnormal  position  of  the  limbs, 
and  amounts  to  actual  deformity. 

The  Long  Bones  are  examined  for  tenderness,  swelHng,  and  frac- 
tures. The  most  common  cause  in  infancy  of  tenderness  and  swel- 
ling over  the  shafts  of  the  long  bones  is  scurvy;  periostitis,  and  osteo- 
myelitis stand  next.  In  older  children,  scurvy  is  not  seen,  and  the 
most  common  cause  is  periostitis.  Tumors,  chiefly  osteosarcoma,  are 
seen  at  times.  The  fingers  should  be  examined  for  tuberculous 
dactylitis. 

The  Joints. — The  physician  should  note  the  contour  of  the  joints 
for  swelling,  should  palpate  them  for  tenderness  and  swelling,  and 
should  manipulate  them  for  pain  on  motion  and  limitation  of  motion. 
It  is  useful  to  remember  that  in  infancy  acute  inflammation  of  the 
joints  usually  represents  a  septic  arthritis,  while  in  older  children. 


^' 


II  .  ?!*»7i 


x 


"^ 


X 


Physical  Examination  99 

it  usually  means  rheumatic  fever.  Chronic  inflammation  of  the 
joints  at  any  period  of  early  Ufe  is  most  commonly  due  to  tuber- 
culosis. A  traumatic  chronic  arthritis  is  not  uncommon  in  children. 
The  chronic  "rheumatoid"  conditions,  osteo-arthritis,  and  so  forth, 
so  often  seen  in  adults,  are  rare  in  childhood. 

THE  SPIXE. — The  spine  is  examined  best  with  the  patient  lying 
on  its  face  on  a  flat  surface.  The  points  to  be  noted  in  connection 
with  the  spine  are  curvatures,  mobility,  tender  points,  and  spina  bifida. 
The  peculiarities  of  spinal  curvature  normally  characteristic  of  early 
life  have  been  described  in  the  section  on  Normal  Development. 
Curvatures  due  to  disease  will  be  apparent  with  the  patient  lying 
on  its  face  A  k}'phosis  is  most  often  due  to  tuberculosis,  while  a 
backward  curve  in  children  is  always  suggestive  of  meningeal  irri- 
tation.    The  lateral  curvatures  are  common  in  childhood. 

The  flexibility  of  the  spine  is  tested  by  grasping  the  heels  of  the 
infant  with  one  hand,  while  the  other  hand  holds  down  the  shoulders. 
The  heels  are  lifted  up,  and  swung  in  various  directions,  as  shown 
in  the  illustration. 

THE  NERVOUS  SYSTEM.— Some  of  the  examinations  made  in 
obtaining  evidence  as  to  disturbance  of  the  nervous  system  have 
already  been  described.  It  is,  however,  useful  to  consider  the  physical 
signs  of  disease  of  the  nervous  system  together,  although  the  various 
steps  in  the  investigation  are  more  conveniently  made  in  connec- 
tion with  other  parts  of  the  physical  examination. 

The  AIental  Contrition  is  estimated  during  the  general  examina- 
tion of  the  body  which  precedes  the  detailed  examination  of  the 
various  organs  and  systems.  It  is  often  advisable,  when  there  is 
any  abnormality  in  the  apparent  mental  attitude  of  the  child,  to 
make  a  more  detailed  investigation  of  the  mental  condition.  This 
cannot  always  be  accompHshed  at  a  single  examination,  and  requires 
more  or  less  prolonged  observation.  Apathy,  stupor,  or  dehrium 
will  usually  be  plainly  apparent  before  the  examination  is  finished. 
Also,  pronounced  cases  of  mental  impairment,  the  severer  grades 
of  idiocy  and  imbecility,  will  not  escape  notice.  It  is  the  milder 
types  of  imbecility  and  backwardness  that  are  not  always  apparent 
on  a  single  examination.  Much  depends  upon  the  physician's  powers 
of  observation,  and  upon  a  very  thorough  familiarity  with  the  behavior 
of  a  normal  child  at  every  stage  of  development. 

Paralysis  and  Spasm.— These  signs  are  most  conveniently  inves- 
tigated during  the  examination  of  the  extremities. 

Paralysis  is  often  diflicult  to  detect  in  young  children.  Older 
children,  who  can  cooperate  with  the  physician,  will  attempt  to  make 
various  movements  as  directed,  and  in  them  the  recognition  of  paralysis 
is  easy  enough.     Infants  and  young  children  will  not  do  this.     The 


100  Disease  in  Early  Life 

motor  function  of  the  arms  can  be  tested  by  offering  them  things  to 
play  with,  or  showing  them  something  which  they  particularly  like, 
such  as  the  bottle  or  a  favorite  toy.  The  power  of  the  legs  is  tested 
by  tickhng  the  feet,  or  pricking  them  with  a  pin.  Sometimes  it 
works  well  to  place  a  limb  in  an  abnormal  strained  position,  and 
note  if  the  child  moves  it  back.  When  a  child  is  unconscious,  the 
only  way  in  which  paralysis  can  be  detected  is  by  lifting  a  limb  and 
then  letting  it  fall,  noting  the  manner  in  which  it  drops.  A  com- 
pletely paralyzed  limb  will  drop  like  a  dead  weight,  while  if  there 
be  no  paralysis,  the  limb  will  drop  neither  so  promptly  nor  so  life- 
lessly. Further  evidence  may  be  obtained  by  manipulating  the 
limb  and  noting  the  amount  of  resistance  to  passive  motion.  Flac- 
cid paralysis  usually  shows  a  notable  difference. 

It  is  very  important  in  infancy  to  distinguish  true  paralysis  from 
the  pseudo-paralysis  which  comes  from  failure  to  use  the  extremities 
on  account  of  pain.  Evidence  of  pain  can  usually  be  found  in  the 
latter  condition,  and  the  two  conditions  can  usually  be  distinguished 
without  causing  too  much  suffering. 

Spasm  is  also  often  difficult  to  detect  in  infants.  In  young  in- 
fants, and  in  all  infants  who  are  notably  emaciated^  there  is  a  hyper- 
tonicity  of  the  muscles  which  must  not  be  mistaken  for  contractures 
of  nervous  origin.  This  hypertonicity  is  most  marked  in  the  flexor 
group  of  muscles,  and  often  prevents  complete  extension  of  the 
hmbs.  When  true  contractures  are  present,  there  is  usually  a  differ- 
ence in  the  amount  of  resistance  to  passive  motion  on  the  two  sides. 

The  test  for  spasm  is  made  by  passive  motion  of  the  limbs  at  the 
various  joints.  It  is  often  difficult  to  distinguish  voluntary  resist- 
ance from  temporary  spasm.  The  former  can  usually  be  overcome 
by  rapid  repetitions  of  the  same  movement,  while  spasm  cannot  thus 
be  overcome.  When  temporary  spasm  is  present,  it  is  important  to 
note  the  position  assumed  by  the  extremities.  In  early  Hfe,  spasm 
is  most  often  due  either  to  disease  of  the  central  nervous  system,  or 
to  hyperirritabihty  of  the  peripheral  nerves  (Spasmophilia). 

The  Reflexes. — The  reflexes  to  be  tested  in  children  as  a  routine 
are  the  pupillary  reaction,  the  knee  jerks,  and  the  plantar  reflex,  and 
certain  special  signs.  The  abdominal  reflex  is  inconstant  in  child- 
hood, and  the  cremasteric  reflex  is  not  of  much  diagnostic  signifi- 
cance. The  method  of  obtaining  the  pupillary  reaction  has  been 
described  under  the  examination  of  the  eye. 

The  knee-jerk  is  often  hard  to  eHcit  in  an  infant.  The  leg  must 
be  relaxed,  and  great  patience  is  often  necessary  before  a  satisfactory 
test  can  be  made.  Too  much  stress  must  not  be  laid  upon  an  absent 
knee-jerk  in  an  infant,  and  it  is  wisest  to  disregard  it  as  evidence 
unless  there  are  some  other  signs  of  disease  of  the  nervous  system. 


Physical  Examination 


101 


An  exaggerated  knee-jerk  has  its  full  diagnostic  significance.  The 
best  method  of  obtaining  the  knee-jerk  in  an  infant  is  to  place  the 
hand  under  the  lower  part  of  the  thigh  and  lift  the  knee  from  the 
bed  or  table.  The  ligamentum  patellae  is  tapped,  the  foot  still  rest- 
ing on  the  bed,  the  angle  of  the  leg  being  varied  by  moving  the  knee 
up  and  down.  Then,  if  no  response  is  obtained,  the  knee  is  lifted 
so  that  the  foot  hangs  clear  of  the  bed,  and  the  tapping  is  repeated. 
In  older  children  the  knee-jerk  is  best  tested  with  the  child  in  a  sit- 
ting posture,  and  the  leg  hanging  free. 


Fig.  29 


Testing  the  knee  jerk 


The  plantar  reflex  is  tested  in  the  ordinary  manner.  In  infancy 
its  presence  is  more  often  shown  by  extension  than  by  flexion  of  the 
toes.  BahinskVs  sign  is  a  simultaneous  extension  of  the  big  toe  and 
flexion  of  the  other  toes,  and  in  adults  and  older  children  it  points 
toward  disease  of  the  higher  motor  tracts.  It  has  no  diagnostic  sig- 
nificance in  infancy. 

Special  Signs  ^— There  are  certain  special  signs  of  great  impor- 
tance in  the  investigation  of  the  nervous  system  in  early  life.  These 
are  Kernig's  sign,  Brudzin-ki's  sign,  ankle  clonus,  the  contralateral 
reflex,   Chvostek's  sign.  Trousseau's  sign,  and  the  peroneal  reflex. 


102       -  Disease  in  Early  Life 

Kernig's  Sign  consists  in  a  limitation  of  the  extension  of  the 
leg  upon  the  thigh  when  the  thigh  is  at  a  right  angle  with  the  body. 
Under  normal  circumstances,  when  the  thigh  is  at  a  right  angle  with 
the  body,  the  leg  can  be  extended  to  an  angle  of  135°  at  the  knee,  at 
least,  and  in  infants  often  to  a  greater  angle.  Kernig's  sign  is  ob- 
tained when  the  leg  cannot  be  extended  to  an  angle  of  135°.  The 
sign  can  be  tested  by  placing  the  thigh  at  a  right  angle  to  the  body 
and  attempting  to  extend  the  leg,  or  by  holding  the  leg  straight  at 

Fig.  30 


Examination  for  Kernig's  sign 

the  knee  and  bringing  the  thigh  to  a  right  angle  with  the  body,  noting 
how  much  flexion  this  causes  at  the  knee.  The  former  method  is 
perhaps  a  little  the  better.  In  very  young,  or  much  emaciated  in- 
fants, the  muscular  hypertonicity  must  be  taken  into  account. 

A  positive  Kernig's  sign  is  almost  constant  in  all  forms  of  menin- 
gitis except  the  tuberculous,  in  which  it  may  or  may  not  be  present. 
It  is  often  positive  in  conditions  other  than  meningitis,  but  usually 
means  meningeal  irritation  of  some  kind. 

Brudzinski's  Neck  Sign.— This  consists  in  a  movement  of  the 
legs  when  the  neck  is  flexed  forward.  Under  normal  conditions 
forward  flexion  of  the  neck  causes  no  movement  of  the  legs.  To  test 
the  neck  sign,  the  child  must  be  lying  on  its  back.     The  physician 


Physical  Examination  103 

holds  the  chest  stationary  with  one  hand,  and  brings  the  head  sharply 
forward  with  the  other.  When  the  sign  is  positive,  this  will  cause 
a  flexion  of  the  legs  both  at  the  hips  and  at  the  knees,  or  at  the  hips 
alone.  The  movement  is  sometimes  present  on  one  side  only.  The 
sign  when  positive  has  been  regarded  by  some  writers  as  diagnostic 
of  meningitis.  It  is  certainly  seen  mainly  in  meningitis,  but  is  not 
present  in  all  cases  of  that  disease,  and  I  have  observed  its  presence 
repeatedly  in  conditions  of  meningeal  irritation  which  were  proved 
not  to  be  meningitis. 

Ftg.  31 


Examination  for  Brudzinski's  neck  sign 

Ankle  Clonus. — This  sign  is  elicited  by  lifting  the  leg  a  few  inches 
from  the  table,  holding  it  straight  at  the  knee  and  making  sharp 
dorsal  flexion  of  the  foot  upon  the  leg,  the  foot  being  held  by  the 
toes.  Ankle  clonus  is  present  if  this  causes  a  rhythmical  jerking  of 
the  foot  back  and  forth  at  the  ankle.  The  sign  is  seen  in  a  great 
variety  of  lesions  of  the  central  nervous  system,  affecting  the  upper 
motor  segment.  It  usually  accompanies  spastic  paralysis.  It  is  one 
of  the  few  signs  which  may  be  present  in  meningitis,  but  which  I 
have  never  observed  in  meningismus. 

The  Contralateral  Reflex  is  present  when  passive  flexion  of 
one  leg  causes  a  reflex  movement  of  the  other  leg.     The  reflex  move- 


104  Disease  in  Early  Life 

merit  may  be  identical  (flexion),  or  reciprocal  (extension).  It  is 
one  of  the  signs  of  disease  of  the  central  nervous  system. 

Chvostek's  Sign  is  tested  by  tapping  upon  the  facial  nerve  or 
its  branches  where  they  cross  the  jaw.  Under  normal  conditions, 
no  contraction  of  the  facial  muscles  is  caused  by  this  procedure,  but 
when  the  sign  is  positive  there  is  a  contraction  which  involves  either 
the  muscles  supplied  by  the  whole  nerve,  or  those  supplied  by  one 
of  its  branches.  The  contraction  is  observed  either  about  the  mouth, 
about  the  eye,  or  about  both.  It  is  a  sharp,  quick  contraction  which 
cannot  be  mistaken  for  voluntary  movement.  The  sign  cannot  be 
obtained  when  the  child  is  crying.  It  is  sometimes  called  the  facial 
phenomenon,  and  the  contraction  about  the  eye,  caused  by  tapping 
the  upper  branch  of  the  facial  nerve  is  sometimes  called  Weiss'  sign. 
Chvostek's  sign  when  positive  is  diagnostic  of  spasmophilia. 

Trousseau's  Sign. — This  is  obtained  by  placing  a  constriction 
band  about  the  upper  arm  near  the  fork  of  the  biceps.  The  con- 
tinued pressure  on  the  nerve  trunks  normally  causes  no  reaction,  but 
in  spasmophilia  this  often  causes  the  hand  to  assume  the  typical 
spasm  of  tetany.  The  sign  when  positive  is  diagnostic  of  spasmo- 
philia, but  its  testing  is  painful,  and  the  diagnosis  can  usually  be  made 
from  other  signs.  It  should  never  be  tried  in  a  case  of  spasmophiha 
characterized  by  laryngospasmus. 

The  Peroneal  Reflex  is  obtained  by  tapping  upon  the  peroneal 
nerve  near  the  head  of  the  fibula.  In  eliciting  this  reflex,  a  percussion 
hammer  is  better  than  the  finger.  The  sign  is  obtained  when  the 
tapping  causes  a  sharp  reflex  movement  of  the  foot.  A  positive 
peroneal  reflex  is  one  of  the  diagnostic  signs  of  spasmophilia. 

Sensation. — In  older  children  who  are  able  to  answer  questions 
intelligently,  sensation  may  be  tested  for  touch,  pain,  and  tempera- 
ture, a^  in  adults.  Testing  the  temperature  sense  is  however  usually 
unnecessary  in  children.  In  young  children  who  are  unable  to  co- 
operate with  the  physician,  only  the  sensation  of  pain  can  be  satis- 
factorily tested.  This  is  performed  by  touching  the  skin  with  a 
sharp  point  and  noting  whether  the  child's  expression  shows  pain, 
or  whether  it  moves  the  limb  out  of  the  way. 

Special  Senses. — For  purposes  of  diagnosis  the  special  senses  to 
be  tested  are  those  of  sight  and  hearing.  In  older  children  who  are 
able  to  answer  questions  intelligently,  the  tests  are  made  as  in  adults. 
In  young  children,  sight  is  tested  by  showing  the  child  some  object 
in  which  it  is  specially  interested,  such  as  the  bottle,  or  a  favorite  toy. 
This  object  is  moved  from  side  to  side,  the  physician  noting  where  the 
patient's  eyes  follow.  In  very  young  babies  not  old  enough  to  recog- 
nize objects,  the  sense  of  sight  is  tested  by  moving  a  bright  light  back 
and  forth  in  front  of  the  eyes  and  noticing  whether  the  movements 


Special  Methods  of  Examination  105 

of  the  eyeball  follow  the  light.  Another  way  is  to  approach  the  hand 
rapidly  to  the  eyes,  noting  whether  the  child  winks.  Care  must  be 
taken  not  to  draw  a  wrong  conclusion  from  winking  caused  by  the 
current  of  air  produced  by  the  movement  of  the  hand.  Hearing  in 
young  children  is  tested  by  making  a  sudden  noise  near  the  ears,  and 
noting  whether  the  child  jumps.  The  test  is  not  always  satisfactory 
in  very  young  babies. 

SPECIAL  METHODS  OF  EXAMINATION 

There  are  certain  special  methods  of  examination  which  frequently 
have  to  be  performed  in  children  for  purposes  of  diagnosis,  but  which 
do  not  form  a  part  of  ordinary  routine  examination.  It  is  essential 
that  the  physician  be  familiar  with  the  technique  of  these  various 
operations. 

LUMBAR  PUNCTURE.— This  is  one  of  the  most  important  diag- 
nostic procedures  used  in  infancy  and  childhood.  It  is  much  more 
frequently  employed  in  children  than  in  adults,  because  not  only 
meningitis  but  many  conditions  simulating  meningitis  are  particu- 
larly common  in  early  life.  There  are  also  other  conditions  more 
common  in  early  Hfe  in  which  lumbar  puncture  is  used,  such  as  hydro- 
cephalus and  poliomyeloencephaHtis. 

The  technique  of  lumbar  puncture  is  comparatively  simple,  but 
success  depends  upon  attention  to  details.  Needles  are  better  than 
trocars  for  lumbar  puncture.  The  size  of  the  needle  should  be 
adapted  to  that  of  the  child.  For  very  young  babies,  an  ordinary 
antitoxin  needle  should  be  used.  For  bigger  babies  and  older  children, 
the  needle  should  be  larger.  Several  needles  and  two  test  tubes 
should  be  boiled,  and  if  the  fluid  has  to  be  transported  for  examina- 
tion, corks  to  fit  the  test  tubes  should  be  boiled  also.  The  hands 
of  the  operator  and  the  lumbar  and  sacral  regions  of  the  patient 
extending  around  as  far  as  the  highest  point  of  the  crest  of  the  ilium, 
are  rendered  surgically  clean.  Tincture  of  iodine  is  useful  to  dis- 
infect the  point  over  the  lumbar  spines  where  the  puncture  is  to  be 
made.  ]Much  depends  upon  the  proper  holding  of  the  patient.  An 
attendant  on  the  opposite  side  of  the  patient  places  one  hand  under 
the  bend  of  the  knees,  and  places  the  other  arm  about  the  patient's 
shoulders.  The  spine  is  then  flexed  by  drawing  up  the  knees  with 
one  hand  and  pressing  the  shoulders  forward.  Pressure  should  be 
made  on  the  region  of  the  shoulders  rather  than  on  the  neck.  It  is 
important  that  the  spine  be  flexed  as  much  as  possible  without  the 
use  of  undue  force.  An  anesthetic  is  unnecessary  in  the  majority 
of  cases,  but  should  be  used  when  muscular  spasm  prevents  proper 
flexion  of  the  spine.  In  some  cases  in  older  children  the  site  of  the 
puncture  may  be  rendered  insensitive  with  cocaine  or  ethyl  chloride. 


106 


Disease  in  Early  Life 


In  many  children,  however,  this  procedure  appears  to  cause  more 
discomfort  and  terror  than  the  puncture  itself. 

The  operator  takes  as  a  landmark  a  line  drawn  between  the  highest 
points  of  the  crests  of  the  ihum  on  each  side.  This  is  the  upper  hmit 
of  safety,  and  the  spinal  canal  can  be  entered  anywhere  below  this 
level  without  danger  of  piercing  the  cord.  It  is  unnecessary  to  count 
and  locate  the  lumbar  spines  by  number.  The  operator  should  take 
as  his  first  point  of  selection  the  second  space  below  the  line  described 
above,  which  gives  him  a  margin  of  one  space  above  and  below  the 
point  first  chosen,  in  case  fluid  is  not  obtained  at  the  first  attempt. 
The  spaces  are  located  with  the  forefinger  of  the  left  hand.     Some 


Fig.  32 


Position  for  lumbar  puncture 

The  dotted  line  shows  the  upper  limit  of  safety,  below  which  the  puncture 

must  be  made 


operators  insert  the  needle  directly  in  the  median  line,  to  pass  between 
the  spines,  others  a  little  to  one  side  of  the  median  line,  to  pass  be- 
tween the  laminae;  in  the  latter  case,  the  needle  must  be  inclined 
shghtly  toward  the  median  line,  so  that  after  insertion  the  point  of 
the  needle  will  be  in  the  median  line. 

The  advantage  of  the  first  point  of  insertion  is  that  the  proper 
direction  is  much  easier  to  follow,  and  of  the  latter  point  that  there  is 
more  room  for  the  needle  to  pass  between  the  laminae  than  between 


I 


,/ 


I 


Special  Methods  of  Examination  107 

the  spines.  I  am  accustomed  to  use  the  latter  method,  but  beheve 
that  both  are  equally  good,  the  choice  depending  upon  the  indi- 
vidual operator.  In  either  case,  the  general  direction  is  horizontally 
forward,  and  the  needle  is  pressed  in  until  the  resistance  opposing 
its  progress  is  felt  suddenly  to  diminish,  when  the  fluid  should  imme- 
diately begin  to  drop  or  spurt  from  the  outer  end  of  the  needle.  The 
fluid  is  caught  in  one  of  the  sterile  test  tubes. 

The  advantage  of  boiling  two  test  tubes  lies  in  the  fact  that  part 
of  the  fluid  will  sometimes  be  blood-stained  and  part  clear,  and  blood- 
stained fluid  interferes  somewhat  with  the  diagnostic  inferences  to 
be  drawn.  If  at  any  time  the  character  of  the  dripping  fluid  changes 
from  clear  to  blood-stained,  or  from  blood-stained  to  clear,  the  second 
test  tube  should  be  substituted. 

The  amount  of  fluid  to  be  withdrawn  depends  upon  the  purpose 
for  which  lumbar  puncture  is  performed.  If  lumbar  puncture  is 
undertaken  for  diagnosis  only,  and  there  are  no  evidences  of  intra- 
dural pressure,  not  more  than  5  c.  c.  should  be  withdrawn.  If  there 
is  evidence  of  intradural  pressure,  as  shown  by  spurting  of  the  fluid, 
the  withdrawal  should  be  continued  until  the  fluid  drops  at  a  normal 
rate. 

If  lumbar  puncture  is  properly  performed,  there  should  be  no  dif- 
ficulty in  obtaining  fluid  in  the  great  majority  of  cases.  Care  should 
be  taken  that  the  needle  is  not  pushed  in  far  enough  to  touch  the 
anterior  wall  of  the  spinal  canal,  as  in  such  a  case  the  fluid  will  prob- 
ably be  blood-stained,  and  if  the  needle  enters  the  tissues  in  the 
anterior  waH,  no  fluid  wifl  flow.  On  the  other  hand,  care  must  be 
taken  that  the  needle  is  pushed  far  enough  to  enter  the  canal.  If 
the  needle  strikes  bone  before  entering  the  canal,  it  is  a  sign  either 
that  the  direction  of  the  needle  is  not  right,  or  that  the  spine  is  not 
sufficiently  flexed  to  permit  the  needle  to  pass  between  the  bones. 
In  the  former  case,  the  needle  must  be  entered  again  with  corrected 
direction;  in  the  latter  case,  a  smaller  needle  must  be  used,  or  increased 
flexion  of  the  spine  must  be  obtained. 

A  "dry  tap,"  or  failure  to  obtain  fluid  may  be  due  to  several  causes. 
The  most  common  is  that  the  needle  has  become  plugged  in  passing 
through  the  tissues,  and  the  physician  should  clear  the  needle  by 
passing  in  the  stylet.  It  may  be  also  that  through  some  fault  of 
technique,  or  some  peculiar  anatomical  condition,  the  needle  has  not 
entered  the  spinal  canal.  In  such  a  case  the  puncture  should  be 
repeated  with  corrected  technique.  If  fluid  still  fails  to  appear,  the 
intervertebral  spaces  above  and  below  the  one  first  chosen,  should 
be  successively  tried.  Even  when  the  operator  is  sure  that  the 
needle  has  entered  the  canal,  a  dry  tap  occasionally  occurs;  this  is 
due  to  some  peculiar  anatomical  or  pathological  cause,  which  prevents 
the  cerebrospinal  fluid  from  reaching  the  lumbar  portion  of  the  canal, 


108  Disease  in  Early  Life 

or  to  the  fact  that  the  fluid  contains  fibrin  or  thick  pus,  and  is  thus 
unable  to  pass  through  the  needle. 

After  the  withdrawal  of  the  needle,  the  puncture  is  covered  with 
a  Httle  piece  of  sterile  absorbent  cotton  held  in  place  by  collodion. 

EXPLORATORY  THORACENTESIS.— This  is  a  most  important 
procedure  in  the  diagnosis  of  pleural  effusion.  The  point  chosen  for 
the  puncture  should  be  that  which  shows  the  greatest  flatness  on 
percussion.  When  the  flatness  is  extensive,  involving  the  whole 
lower  portion  of  the  pulmonary  area,  the  point  of  selection  should  be 
in  the  posterior  axillary  line,  at  the  sixth  interspace  on  the  left,  and 
at  the  fifth  interspace  on  the  right.  Fluid  should  always  be  obtained 
at  these  points  when  the  pleural  cavity  contains  free  fluid;  but  in 
cases  of  encapsulated  fluid,  the  point  for  the  puncture  must  be  de- 
termined by  physical  examination.  The  needle  used  in  making  the 
puncture  should  be  about  one  millimeter  in  diameter.  The  needle  and 
syringe  should  be  boiled. 

The  child  is  held  firmly  in  a  sitting  position,  the  hand  on  the  side 
to  be  punctured  being  brought  up  over  the  opposite  shoulder,  and  the 
skin  is  rendered  surgically  clean.  The  needle,  attached  to  the 
syringe  is  introduced  between  the  ribs,  nearer  to  the  upper  than  the 
lower  border  of  the  rib,  in  order  to  avoid  injuring  the  intercostal 
artery  which  runs  along  the  lower  border.  The  distance  which  the 
needle  enters  is  from  i  to  2  cm.  The  entrance  into  the  pleural  cav- 
ity can  usually  be  detected  by  a  sudden  diminution  in  the  resistance. 
The  piston  of  the  syringe  is  then  gently  drawn,  and  if  fluid  be  reached 
it  will  enter  the  syringe.  If  fluid  is  not  obtained,  it  should  not  be 
sought  by  moving  about  the  point  of  the  needle,  but  the  needle  should 
be  withdrawn,  and  after  a  second  careful  physical  examination,  it 
should  be  introduced  in  another  place.  After  withdrawing  the  needle 
upon  failure  to  obtain  fluid  at  any  point,  it  is  well  to  make  sure  that 
the  lumen  of  the  needle  is  clear.  The  wound  left  by  the  needle  may 
be  covered  by  a  bit  of  sterile  cotton  and  collodion.  In  seeking  for 
encapsulated  fluid,  almost  any  part  of  the  chest  may  be  safely  en- 
tered, but  it  is  well  to  avoid  the  region  near  the  heart.  Performed 
in  this  way,  exploratory  puncture  is  practically  without  danger,  even 
if  the  needle  enters  the  lung. 

EXPLORATORY  PUNCTURE  OF  THE  PERITONEAL  CAV- 
ITY.—This  procedure  is  very  rarely  employed.  The  diagnosis  of 
ascites  should  depend  upon  the  results  of  physical  examination,  and 
exploratory  puncture  is  not  a  safe  procedure  to  determine  the  pres- 
ence or  absence  of  fluid.  It  is  only  made  in  cases  in  which  the  diag- 
nosis of  ascites  is  clear,  for  the  purpose  of  obtaining  fluid  for  bacteri- 
ological and  cyto-diagnostic  examination.  The  syringe,  needle,  and 
preparations  are  the  same  as  for  thoracentesis.     It  is  essential  that 


Special  Methods  of  Examination  109 

the  bladder  be  first  emptied  by  catheterization.  The  child  should 
be  in  a  sitting  posture,  and  the  needle  is  introduced  half-way  between 
the  pubes  and  the  umbilicus. 

EXPLORATORY  PUNCTURE  OF  THE  PERICARDIAL  CAV- 
ITY.—Puncture  of  the  pericardial  cavity  is  also  rarely  employed 
for  diagnostic  purposes.  The  diagnosis  of  pericardial  effusion  should 
rest  on  the  results  of  physical  examination.  In  rare  cases  explora- 
tory puncture  may  be  made  to  obtain  fluid  for  examination.  The 
usual  purpose,  however,  of  entering  the  pericardial  cavity  is  the  with- 
drawal of  fluid  as  a  therapeutic  measure.  The  technique  of  this 
operation  will  be  described  in  the  article  on  Pericarditis. 

EXAMINATION  OF  GASTRIC  CONTENTS  AND  RETEN- 
TION TIME. — This  procedure  is  of  importance  in  the  diagnosis  of 
pyloric  stenosis  and  pyloric  spasm.  It  also  often  throws  light  upon 
gastric  digestion,  and  sometimes  reveals  the  presence  of  dilatation 
of  the  stomach.  The  apparatus  used  consists  of  a  soft  rubber  cathe- 
ter of  a  size  from  14  to  18  French  scale.  This  is  connected  by  a 
piece  of  glass  tubing  with  a  rubber  tube  attached  to  the  nozzle  of  a 
glass  bulb;  to  the  opposite  nozzle  of  the  glass  bulb,  another  piece 
of  rubber  tubing  is  attached.  A  measured  quantity  is  given  at  a 
feeding,  and  the  contents  are  withdrawn  at  whatever  period  after  the 
feeding  time  it  is  desired  to  obtain  them. 

In  estimating  gastric  retention  time,  it  is  desirable  as  a  routine 
to  withdraw  the  contents  after  one  hour,  and  again  after  three  hours. 
After  one  hour,  the  stomach  is  usually  not  empty,  but  much  less 
should  be  obtained  than  was  given.  After  two  or  three  hours,  the 
stomach  should  be  empty.  In  withdrawing  the  gastric  contents,  the 
catheter  is  passed  into  the  stomach,  and  the  physician  applying  his 
mouth  to  the  tube  draws  the  fluid  into  the  bulb.  The  amount  of 
fluid  withdrawn  should  always  be  measured. 

EXAMINATION  BY  DUODENAL  CATHETER.— The  tech- 
nique of  this  operation  is  described  under  the  heading  of  Spasm  of 
the  Pylorus. 

TESTING  THE  ELECTRICAL  REACTION.— This  requires 
special  apparatus.  There  are  a  number  of  good  batteries  on  the 
market  available  for  this  purpose.  The  essentials  are,  an  appli- 
ance for  reversing  the  direction  of  the  current,  so  that  the  anodal 
and  cathodal  reactions  may  be  tested  without  changing  the  position 
of  the  electrode.  There  must  also  be  an  appliance  for  measuring  the 
strength  of  the  current  used,  graduated  in  milHamperes.  The  indif- 
ferent electrode  is  appHed  to  the  front  of  the  chest  or  any  portion  of 
the  body,  while  the  differentiating  electrode  is  applied  to  the  nerve 
or  muscle  to  be  tested. 


110  Disease  in  Early  Life 

LARYNGOSCOPY. — This  procedure  is  mainly  used  in  older  chil- 
dren.    The  technique  is  that  for  adults. 

OPHTHALMOSCOPY.— This  is  very  difficult  in  infants  on  ac- 
count of  the  movements  of  the  eyeball.  The  technique  in  childhood 
is  the  same  as  in  adults. 

RECTAL  EXAMINATION.— This  procedure  is  frequently  in- 
dicated in  children,  in  obscure  conditions  in  the  abdominal  cavity. 
The  child  should  be  lying  on  its  back.  The  physician  inserts  the 
oiled  finger  into  the  rectum,  while  with  the  other  hand  he  makes 
palpation  through  the  abdominal  wall.  There  is  no  danger  in  intro- 
ducing the  forefinger  into  the  rectum,  even  a  small  baby's,  provided 
that  the  introduction  be  made  slowly  enough  to  dilate  the  sphincter. 
A  much  greater  area  may  be  reached  in  infants  than  in  older  children 
and  adults,  and  for  this  reason  rectal  examination  often  throws  very 
valuable  light  on  the  diagnosis  in  infants. 

ROENTGEN-RAY  EXAMINATION.— This  is  by  far  the  most 
important  and  valuable  of  all  the  special  diagnostic  procedures  used 
in  early  life.  Owing  to  the  fact  that  the  soft  parts  in  children  are 
less  thick,  the  results  of  Roentgen-ray  examination  are  more  valuable 
in  children  than  in  adults,  and  in  babies  than  in  older  children.  When- 
ever possible,  Roentgen-ray  examination  of  the  chest  should  be  car- 
ried out  in  all  cases  of  suspected  tuberculosis,  or  suspected  disease 
of  the  lungs,  pleura,  heart,  pericardium,  or  thymus.  It  should  be 
carried  out  in  all  suspected  cases  of  disease  of  the  bones  or  joints. 
It  is  sometimes  valuable  in  intracranial  disease.  One  of  the  most 
important  uses  of  Roentgen-ray  examination  is  in  the  investigation 
of  the  gastro-intestinal  system.  This  is  carried  out  by  means  of  the 
bismuth  meal,  or  the  bismuth  enema. 

For  the  technique  of  these  investigations  and  the  interpretation 
of  their  results,  the  reader  is  referred  to  standard  textbooks  on 
roentgenology. 

LABORATORY  METHODS  OF  DIAGNOSIS 

The  importance  of  laboratory  methods  of  diagnosis  in  the  diseases 
of  early  life  cannot  be  overestimated.  The  laboratory  has  come  to 
occupy  a  more  and  more  important  place  in  modern  diagnosis.  There 
is,  however,  a  tendency  to  neglect  laboratory  methods  in  the  dis- 
eases of  infancy  and  childhood.  This  is  a  very  great  mistake.  In- 
deed, there  are  some  conditions  almost  pecuHar  to  early  Hfe,  such  as 
for  example,  pyelitis,  in  which  the  diagnosis  depends  entirely  upon 
the  results  of  laboratory  investigation. 

The  laboratory  methods  of  diagnosis  which  are  used  in  infancy 
.and   childhood,   do  not  differ  either  in  character  or  in  technique 


Special  Methods  of  Examination 

Fig.  34 


111 


Infant,  6  months  old.     Taken  under  chloruform  from  l.iehind.     Stomach  and  large  intes- 
tine distended  with  gas.     i,  right  lung;  2,  left  lung;  3,  heart;  4,  liver; 
5,  stomach;  6,  left  kidney;  7,  right  kidney;  8,  ascending  colon; 
9,  descending  colon;  10,  probably  the  head  of  the  pancreas 


112  Disease  in  Early  Life 

from  those  used  in  investigating  disease  in  adults.  The  significance 
and  relative  importance  of  the  various  tests  are  however  in  many 
cases  widely  different  in  early  life  and  in  adult  life.  It  is  for  this 
reason  that  the  tests  are  here  enumerated  and  described.  The  tech- 
nique of  the  various  tests  is  described  for  purposes  of  convenience 
of  reference  and  of  completeness. 

THE  URINE. — The  examination  of  the  urine  in  childhood  is 
often  neglected.  This  is  due  partly  to  the  impression  that  the  re- 
sults of  the  clinical  examination  of  the  urine  in  children  are  not  of 
such  great  diagnostic  significance  as  in  adults,  but  mainly  to  the 
difficulty  of  obtaining  urine  from  infants.  The  examination  of  the 
urine  should  be  a  routine  measure  in  the  investigation  of  every  case 
of  disease  in  infancy  and  childhood. 

Technique  for  Obtaining  the  Urine  of  Infants. — In  male 
infants,  the  best  method  of  obtaining  urine  for  examination  is  by  the 
application  of  a  clean  test  tube  to  the  baby's  penis.  This  is  held  in 
place  by  a  strip  of  adhesive  plaster,  as  shown  in  the  illustration. 
If  the  test  tube  be  properly  applied  and  left  in  place,  the  urine  passed 
will  be  collected  in  the  test  tube.  It  is  possible  by  this  method  to 
obtain  all  the  urine  excreted  in  twenty-four  hours. 

In  female  infants,  the  obtaining  of  a  specimen  of  urine  for  exam- 
ination is  more  difficult.  I  am  accustomed  to  use  an  apparatus 
like  that  shown  in  the  illustration.  It  is  simply  placed  in  the  proper 
position  inside  the  diaper,  which  holds  it  in  place.  In  many  cases 
it  is  impossible  to  obtain  immediately  a  specimen  of  urine.  In  such 
cases  catheterization,  which  is  a  very  simple  procedure  in  female 
infants,  should  be  employed. 

Clinical  Examination  of  the  Urine. — -The  chemical  and  micro- 
scopic tests  used  in  the  examination  of  the  urine  of  children  do  not 
differ  from  the  tests  in  adults.  For  this  reason  it  is,  perhaps,  un- 
necessary to  describe  them.  Nevertheless,  as  there  are  differences 
in  the  relative  importance  of  the  various  tests  in  childhood  and  in 
adult  fife,  and  also  some  differences  in  the  diagnostic  significance  of 
the  tests,  they  will  be  briefly  described  here  for  purposes  of  point- 
ing out  these  differences,  and  of  completeness.  It  is  important  to 
note  the  frequency  of  micturition  in  all  cases.  It  should  be  remem- 
bered that  in  infants  the  normal  frequency  is  very  great  when  the 
baby  is  awake,  the  urine  often  being  passed  two  or  three  times  an 
hour;  in  sleep  it  is  retained  longer,  from  two  to  six  hours.  After  the 
first  two  years,  the  normal  time  in  which  the  urine  is  retained  during 
sleep  is  very  variable,  and  as  the  child  grows  older,  the  frequency 
by  day  gradually  diminishes.  The  age  at  which  control  of  the  sphinc- 
ter of  the  bladder  is  attained,  is  also  very  variable.     Under  normal 


Fig.  35 — Obtaining  urine  from  male  infant 


Laboratory  Diagnosis 


113 


Fig.  36— Apparatus  for  obtaining  urine  from  a  female  infant 


\    . 
\ 

\ 

1 

> 

1 

1 

1 

Fig.  37 — Method  of  collecting  urine  from  a  female  infant 
A.  Cut  rubber  finger  cot.    B.  Adhesive  plaster  for  attachment.    C.  Test  tube. 
D.  Apparatus  complete 
8 


114 


Disease  in  Early  Life 


circumstances,  the  diaper  may  sometimes  be  dispensed  with  as  early 
as  one  year,  and  in  other  cases,  not  until  two  years,  or  even  later. 

The  tests  may  be  divided  into  those  which  should  form  part  of 
every  routine  examination,  and  those  which  need  only  be  employed 
occasionally  for  a  definite  purpose.  The  tests  used  in  the  routine 
examination  of  the  urine  will  be  described  first. 

Physical  Character  and  Reaction.  —  The  color,  odor,  specific 
gravity,   turbidity,  and  amount  and  character  of  sediment  should 


Fig.  38 


Catheterization  of  a  female  infant 


first  be  noted.  The  urine  of  the  newly  born  infant  is  usually  some- 
what highly  colored.  During  the  rest  of  infancy  the  normal  color 
is  pale  in  comparison  with  that  of  older  children  and  of  adults.  The 
normal  odor  has  no  peculiarity  in  infancy  and  childhood.  A  strongly 
ammoniacal  odor  in  infants  is  seen  in  some  cases  of  malnutrition  and 
gastro-intestinal  disease.  Except  in  the  first  few  days  of  life,  the 
reaction  of  the  urine  in  infancy  is  faintly  acid  or  neutral.  In  older 
children  it  is  acid.  In  the  first  days  of  Hfe  it  is  strongly  acid,  and 
often  shows  a  deposit  of  urates  or  uric  acid,  which  appears  as  a  pink- 
ish or  reddish-yellow  stain  upon  the  napkin.  The  normal  specific 
gravity  at  the  various  ages  is  as  follows: 


Laboratory  Diagnosis  115 

Table  12 

The  first  two  or  three  days i.oio  to  1.012 

Fourth  to  fourteenth  day i  .003  to  i  .006 

Fourteenth  day  to  sixth  month i .  004  to  i .  010 

Six  months  to  two  years i .  006  to  i .  01 2 

Two  to  eight  years i  .008  to  i  .016 

Eight  to  fourteen  years i  .012  to  i  .020 

Slight  turbidity  of  the  urine  is  not  uncommon  in  infancy.  Under 
normal  conditions  it  may  be  due  to  the  presence  of  mucus,  in  which 
case  it  cannot  be  entirely  removed  by  filtration,  or  to  the  presence  of 
urates.  Cloudiness  due  to  urates  will  disappear  on  heating.  Patho- 
logical causes  of  turbidity  are  phosphates,  bacteria,  or  pathological 
sediment,  which  in  early  life  is  usually  pus.  The  cause  of  turbidity 
should  always  be  determined.  Cloudiness  due  to  bacteria  is  recog- 
nized by  the  fact  that  it  is  not  diminished  by  ordinary  filtration. 
Phosphates  are  recognized  by  the  fact  that  the  turbidity  disappears 
when  a  few  drops  of  acetic  acid  are  added.  Pus  is  suspected  from 
exclusion  of  the  other  causes,  the  suspicion  being  confirmed  by  the 
microscopic   examination. 

Albumin. — For  routine  use,  the  best  test  for  albumin  is  the  heat 
test,  which  is  performed  as  follows:  Filter  about  10  c.c.  of  urine  into 
a  test  tube,  and  boil  the  upper  half  of  the  fluid.  Add  one  or  two 
drops  of  acetic  acid  (36  per  cent.),  and  boil  again.  A  precipitate 
which  appears  on  boiling,  and  persists  after  the  addition  of  the  acid, 
or  which  appears  on  the  second  boiling,  is  albumin.  Care  must  be 
taken  not  to  use  an  excess  of  acid. 

An  approximate  idea  of  the  quantity  of  the  albumen  can  be  ob- 
tained from  the  heat  test  by  allowing  the  albuminous  precipitate  to 
settle,  i/ioo  per  cent,  or  less  causes  turbidity  but  no  precipitate. 
With  1/20  per  cent,  the  bottom  of  the  test  tube  is  covered;  i/io  per 
cent,  occupies  i/io  the  volume  of  the  column  of  urine;  while  1/2  per 
cent,  occupies  1/3  of  the  volume;  and  one  per  cent,  half  the  column. 
Albumin  amounting  to  two  or  three  per  cent.,  becomes  converted 
into  a  compact  coagulum. 

When  in  the  performance  of  the  heat  test  the  addition  of  acetic 
acid  gives  a  heavy  precipitate  which  partially  clears  on  boihng,  it 
suggests  the  presence  of  the  Bence- Jones  body  (often  incorrectly 
spoken  of  as  albumose) .  The  presence  of  this  substance  is  confirmed 
after  filtering  the  contents  of  the  tube  while  hot  by  the  appearance 
of  a  cloud  in  the  filtrate  on  cooling. 

Albumin  may  be  normally  present  in  small  amount  in  the  urine 
during  the  first  days  of  hfe.  Later  its  presence  has  the  same  signifi- 
cance as  in  adults. 

Sugar. — Fehling's  test  is  best  for  routine  qualitative  examina- 
tion. Mix  in  a  test  tube  5  c.c.  of  each  of  Fehling's  two  solutions. 
Boil,  and  then  add  slowly  5  c.c.  of  urine.     Separate  in  two  portions 


116  Disease  in  Early  Life 

in  two  test  tubes.  Boil  one  of  these  portions.  If  no  precipitate 
appears,  sugar  is  absent;  a  precipitate  may  or  may  not  be  sugar.  Set 
the  other  portion  aside  without  further  heating.  If  a  precipitate 
appears,  the  presence  of  sugar  is  confirmed.  When  the  sugar  is  very 
small  in  amount,  the  precipitate  may  take  from  fifteen  minutes  to 
several  hours  in  appearing.  For  the  methods  by  which  the  presence 
of  sugar  is  confirmed  by  other  tests,  the  reader  is  referred  to  standard 
works  on  physiological  chemistry. 

It  is  usually  stated  that  sugar  may  be  present  in  the  urine  of  normal 
infants  during  the  first  two  months.  This  is  true,  but  I  have  also 
found  it  occasionally  in  the  urine  of  normal  infants,  or  of  infants 
suffering  from  mild  gastro-intestinal  disturbances,  up  to  the  age  of 
tM^o  years.  It  is  very  much  more  frequently  absent  than  present. 
Creatinin  is  normally  present  in  the  urine  of  infants,  and  occasionally 
is  present  in  sufficient  amounts  to  reduce  FehHng's  solution.  Many 
writers  have  mistaken  this  reduction  for  sugar.  Creatinin  can  be 
excluded  by  shaking  the  urine  with  picric  acid,  filtering,  and  repeat- 
ing FehHng's  test,  which  will  be  negative  if  the  reduction  was  caused 
by  creatinin.  In  connection  with  the  appearance  of  sugar  in  the 
urine  of  infancy,  the  statement  of  Grosz  is  often  quoted,  that  sugar 
appears  if  the  quantity  of  sugar  given  in  the  food  is  increased  to  a 
certain  amount  in  proportion  to  the  body  weight  of  the  infant.  In 
some  experimental  work  performed  by  Dr.  Langley  Porter  and  the 
writer,  the  results  failed  to  confirm  this  statement.  We  were  unable 
to  cause  the  appearance  of  sugar,  or  an  increase  in  the  amount  of 
sugar,  by  giving  large  amounts  of  lactose  or  maltose  in  the  food. 

For  the  most  accurate  quantitative  test  for  dextrose  in  the  urine, 
such  as  that  with  Benedict's  solution,  the  reader  is  referred  to  stand- 
ard works  on  physiological  chemistry. 

The  simplest  quantitative  estimation  for  routine  use  can  be  made 
by  means  of  the  fermentation  test.  To  loo  c.c.  of  urine  of  known 
specific  gravity,  add  one- third  of  a  yeast  cake  broken  into  very  small 
pieces.  Set  in  a  warm  place  for  twenty-four  hours.  If  at  the  end  of 
this  time  there  is  no  reduction  with  Fehling's  solution,  take  the  specific 
gravity;  otherwise  continue  the  fermentation  till  no  reduction  is 
obtained.  Multiply  the  difference  in  specific  gravity  before  and 
after  fermentation  by  0.23  to  get  the  per  cent,  of  dextrose  present. 

Acetone. — The  test  for  acetone  should  form  part  of  the  routine 
examination  of  the  urine  in  infancy  and  childhood.  The  presence 
of  the  acetone  bodies  is  of  great  diagnostic  importance  in  the  dis- 
eases of  early  life.  Their  significance  will  be  considered  under 
Acidosis. 

To  one-sixth  of  a  test  tube  of  urine  add  a  crystal  of  sodium  nitro- 
prusside.     Shake  thoroughly  until  the  crystal  is  dissolved,  and  then 


Laboratory  Diagnosis  117 

add  a  few  drops  of  glacial  acetic  acid,  shaking  again.  Pour  carefully- 
down  the  side  of  the  test  tube  5  c.c.  of  ammonium  hydrate.  A  purple 
ring  where  the  ammonia  meets  the  urine  demonstrates  the  presence 
of  acetone. 

Sediment. ^Whenever  there  is  any  visible  sediment,  it  should  be 
examined  microscopically  as  a  routine.  The  things  to  be  looked  for 
are  pus,  casts,  blood,  epithelial  cells,  crystals,  fat,  and  bacteria. 

The  following  tests  need  not  be  made  as  a  routine,  but  are  of 
occasional  value  and  should  be  made  whenever  their  need  is  suggested 
by  the  cHnical  features  of  the  case. 

Bile. — The  reagent  consists  of  tincture  of  iodine  one  part,  alcohol 
fifteen  parts.  Pour  i  c.c.  of  this  reagent  on  the  top  of  the  urine  in  the 
test  tube.  A  green  ring  at  the  junction  of  the  two  fluids  shows  the 
presence  of  bile.  This  test  should  be  performed  whenever  there  is 
any  suspicion  of  jaundice. 

Blood  is  recognized  from  the  color  of  the  urine,  and  from  the  ex- 
amination of  the  sediment.  Blood  pigment  may  be  present  in  solu- 
tion, as  in  haemoglobinuria.  Its  presence  is  demonstrated  by  the 
guaiac  test,  which  will  be  described  under  the  examination  of  the  feces. 

Indican. — -To  15  c.c.  of  urine  add  3  c.c.  of  a  20  per  cent,  solution 
of  lead  acetate.  Filter.  To  the  filtrate  add  an  equal  volume  of  a 
reagent  made  up  of  0.4  gram  ferric  chloride  in  100  c.c.  of  concentrated 
hydrochloric  acid.  Shake  for  two  minutes.  Add  3  c.c.  of  chloro- 
form and  again  shake.  If  indican  be  present  in  considerable  quan- 
tity, the  chloroform  will  assume  a  deep  blue  color.  This  is  known 
as  Obermeyer's  test.  An  excess  of  indican  in  the  urine  of  infants 
and  children  is  usually  significant  of  acute  or  chronic  intestinal  dis- 
ease. It  is  more  or  less  a  measure  of  the  amount  of  protein  putre- 
faction going  on  in  the  intestine.  Indicanuria  is  also  seen  in  exten- 
sive suppurative  processes  without  drainage  in  various  parts  of  the 
body,  such  as  empyema.  Indicanuria  is  not  of  very  great  importance 
either  as  a  diagnostic  measure,  or  as  a  measure  of  the  results  of 
treatment  in  intestinal  diseases.  It  is  said  to  be  an  important  finding 
in  pellagra. 

DiACETic  Acid. — Add  a  strong  aqueous  solution  of  ferric  chloride 
to  one-third  of  a  test  tube  of  urine.  A  Burgundy-red  color  shows  the 
presence  of  diacetic  acid.  If  the  reaction  takes  place  after  the  urine 
has  been  previously  boiled,  it  is  not  due  to  diacetic  acid.  Diacetic 
acid  is  one  of  the  acetone  bodies  which  are  found  in  acidosis.  The 
test  is  performed  whenever  acidosis  is  suspected,  or  when  the  routine 
test  for  acetone  is  positive.  Whenever  diacetic  acid  is  found  in  the 
urine,  it  is  probable  that  /3-oxybutyric  acid  is  also  present. 

Tubercle  Bacilli. — To  find  tubercle  bacilli  in  the  sediment, 
the    following    technique    should    be    employed:     i.    Centrifugalize. 


118  Disease  in  Early  Life 

Decant  supernatant  fluid,  dilute  with  water,  recentrifugalize,  and 
make  a  cover  glass  preparation  from  the  sediment.  This  should  be 
spread  thinly,  and  held  in  the  fingers  over  a  flame  of  a  Bunsen  burner 
until  dry.  Place  the  cover  glass  in  the  forceps  and  fix  by  passing 
three  times  through  the  flame.  2.  Cover  the  preparation  thoroughly 
with  carbol-fuchsin  solution  and  steam  over  the  flame  for  half  a  min- 
ute. Do  not  allow  the  staining  solution  to  dry  on  the  surface  of  the 
cover  glass,  but  add  more  stain  if  necessary.  3.  Wash  in  water.  4. 
Decolorize  for  twenty  seconds  in  20  per  cent,  sulphuric  acid.  5.  Wash 
in  water.  6.  Wash  in  95  per  cent,  alcohol  for  thirty  seconds,  or  until 
no  more  color  will  come  out.  7.  Wash  in  water.  8.  Cover  the  prepa- 
ration vdth  Lofiier's  methylene-blue  solution  for  thirty  seconds.  9. 
Wash  in  water,  dry  and  mount.  Tubercle  bacilH  are  bright  red; 
nuclei  and  other  bacteria  are  blue. 

GoNOCOCCUS. — The  technique  of  staining  the  sediment  of  the 
urine  for  gonococci  is  the  same  as  that  used  in  the  examination  of 
the  vaginal  discharge,   arid  will  be  described  under  that  heading. 

EXAMINATION  OF  THE  BLOOD.— For  ordinary  cHnical  ex- 
amination, blood  is  obtained  from  infants  and  children  as  in  adults. 
The  lobe  of  the  ear  is  cleansed  with  water,  thoroughly  dried,  and 
quickly  pierced  with  a  clean  surgical  needle. 

Hemoglobin.  —  For  the  ordinary  estimation  of  the  per  cent,  of 
hemoglobin,  Tallqvist's  scale  is  sufiiciently  reliable.  If  it  be  desired 
to  make  an  accurate  estimation,  some  such  apparatus  as  the  Fleischl- 
Miescher  or  Sahh  must  be  used.  The  presence  or  absence  of  anemia 
can  be  determined  by  Tallqvist's  method.  The  standard  by  which 
anemia  is  estimated  in  early  life  is,  however,  entirely  difi'erent  from 
that  used  in  adult  life.  The  percentage  of  hemoglobin  in  the  blood 
is  highest  in  the  newly  born,  and  rapidly  falls  in  the  first  few  days 
of  hf e.  It  is  considerably  lower  than  in  adult  fife  throughout  childhood, 
being  lowest  during  infancy,  and  gradually  increasing  after  the  second 
year  up  to  the  age  of  puberty,  when  the  adult  standard  is  reached. 
As  measured  by  the  adult  standard,  the  lowest  normal  limit  would  be 
represented  by  65  per  cent  on  Tallqvist's  scale.  The  usual  range 
in  infancy  and  childhood  is  from  65  to  85  per  cent. 

Leucocytosis. — The  presence  or  absence  of  leucocytosis  is  deter- 
mined by  means  of  the  white  count.  Draw  the  blood  into  the  Toma- 
Zeiss  white  blood  counter  up  to  the  0.5  mark,  and  then  draw  in  0.5 
per  cent,  acetic  acid  up  to  the  11  mark.  ]\lix  thoroughly  by  shaking 
and  revolving  the  counter.  Count  all  the  corpuscles  on  the  ruled 
field.  Clean  the  slide  and  make  a  second  count.  Add  the  two  counts 
together,  multiply  by  100,  and  the  product  is  the  number  of  white 
corpuscles  per  cubic  millimeter. 


Laboratory  Diagnosis  119 

The  normal  standard  differs  notably  from  that  of  adult  life.  Normal 
variations  in  infancy  are  from  8,000  to  ij,ooo,  and  in  later  childhood 
from  6,000  to  ij,ooo. 

The  Red  Corpuscles. — The  count  of  the  red  corpuscles  is  made 
as  follows:  Draw  the  blood  into  the  Toma-Zeiss  red  counter  up  to 
the  0.5  mark,  and  dilute  with  Gower's  solution  up  to  the  loi  mark. 
Mix  thoroughly  by  shaking  and  revolving  the  counter.  Place  a  drop 
of  blood  on  the  slide  of  the  counter,  cover  with  the  glass,  and  count 
the  corpuscles  in  twenty-five  small  squares  at  each  of  the  four  corners 
of  the  ruled  field,  and  multiply  the  total  by  8,000,  This  gives  the 
number  of  red  cells  in  a  cubic  millimeter  of  blood.  For  greater 
accuracy  it  is  well  to  repeat  this  procedure  with  a  second  slide,  and  take 
the  average. 

The  number  of  red  corpuscles  at  birth  is  high,  although  there  is 
some  diversity  of  opinion  as  to  the  actual  number.  It  is  between 
5,350,000  and  6,000,000.  There  is  an  increase  in  the  first  two  or 
three  days  of  life,  and  the  count  may  be  from  6,000,000  to  7,500,000. 
This  increase  is  probably  only  relative,  being  due  to  loss  of  fluid, 
and  the  delay  in  the  establishment  of  nutrition.  After  the  first  few 
days,  the  count  falls  rapidly,  reaching  the  normal  figures  for  infancy 
at  about  two  weeks.  The  normal  standard  for  infancy  ranges  from 
5,000,000  to  6,000,000.  It  gradually  falls  during  early  childhood, 
reaching  the  adult  standard  of  4,500,000  to  5,000,000  at  about  six 
years. 

Examination  of  the  Stained  Specimen. — Cover  glasses  should 
be  thoroughly  washed  with  soap  and  water,  and  wiped  dry.  The 
center  of  a  cover  glass  held  by  its  edges  is  touched  against  the  summit 
of  the  drop  of  blood,  touching  the  skin  being  avoided.  Drop  the 
cover  glass  upon  another  clean  cover  glass,  allowing  the  blood  to 
spread  evenly  between  them  without  pressure.  Hold  the  cover 
glasses  by  their  edges,  and,  keeping  their  faces  parallel,  draw  them 
quickly  apart.  When  dry,  they  are  ready  for  staining.  No  heat 
is  required.  Cover  the  specimen  with  five  drops  of  Wright's  modifi- 
cation of  Leishman's  blood  stain,  for  one  minute.  Add  with  a  medi- 
cine dropper  ten  drops  of  water,  and  let  the  diluted  stain  remain  on 
the  slide  for  two  minutes.  Wash  in  water  (not  running  water)  until 
the  film  has  a  pinkish  color.     Dry  and  mount. 

The  features  to  be  noted  in  the  microscopic  examination  of  the 
stained  specimen,  are  the  following: 

1.  The  relative  number  of  the  different  varieties  of  white  corpuscles. 

2.  The  appearance  of  the  red  corpuscles.  The  points  to  be  noted 
are  variations  in  size  (makrocytes  and  mikrocytes),  variations  in  shape 
(poikilocy tosis) ,  loss  of  color  (achromia),  stippling,  abnormality  of 
staining    (polychromatophilia) ,    tendency    toward    predominance    of 


120  Disease  in  Early  Life 

large  or  small  forms,  and  the  presence  and  relative  number  of  nucleated 
forms  (normoblasts  and  megaloblasts) . 

3.  The  number  of  blood  platelets. 

4.  The  presence  or  absence  of  parasites,  particularly  those  of  malaria. 
Five  varieties  of  white  corpuscles  are  found  normally  in  human 

blood,  and  these  are  classified  as  follows  by  Ehrlich: 

1.  Lymphocytes  (Plate  XV).  These  are  about  the  size  of  a  red 
corpuscle,  and  contain  one  large,  round,  deeply  staining  nucleus 
which  entirely  fills  the  cell.  The  protoplasm  is  not  granular  and 
stains  faintly  or  not  at  all. 

2.  Large  Mononuclear  (Plate  XV).  These  cells  are  much  larger 
than  the  lymphocytes.  They  have  one  large  oval  nucleus  with  a 
broad  margin  of  non-granular,  almost  colorless  protoplasm  about  it. 

3.  Transitional  (Plate  XV).  These  cells  are  derived  from  the  last 
form  and  are  similar  in  size  and  color.  The  nucleus  is  indented  on 
one  side  as  the  result  of  the  beginning  of  nuclear  division. 

These  three  varieties  are  sometimes  called  basophiles. 

4.  Polynuclear  Neutrophiles  (Plate  XV).  These  are  round  cells, 
smaller  than  the  large  mononuclear,  having  a  peculiar  polymorphous 
deeply  staining  nucleus.  The  nucleus  is  long,  irregular  or  twisted, 
and  when  stained  often  appears  segmented.  The  protoplasm  con- 
tains fine  granules  which  are  stained  by  both  the  acid  and  basic 
stains. 

5.  Polynuclear  Eosinophiles  (Plate  XV).  These  are  usually  about 
the  size  of  neutrophiles  and  have  a  deeply  stained  polymorphous 
nucleus.  The  protoplasm  contains  granules  which  are  much  coarser 
than  those  of  the  neutrophiHc  cells,  and  which  stain  readily  with 
acid  stains. 

These  cells  are  sometimes  called  oxyphiles. 

6.  Myelocytes  (Fig.  39).  These  are  round  or  ovoid  cells  with 
one,  rarely  two,  large  round  or  slightly  bent  nuclei  which  stain  Hght 
blue.  There  are  two  varieties,  neutrophilic  and  eosinophilic.  The 
first  has  a  protoplasm  crowded  with  fine  neutrophilic  granules.  The 
second  contains  coarse  eosinophilic  granules.  Myelocytes  rarely 
appear  in  normal  blood,  but  are  much  increased  in  some  of  the  path- 
ological states. 

7.  Mast-Cells. — These  are  coarse,  granular  basophiles,  usually 
with  a  trilobar  nucleus.  The  protoplasm  with  Wright's  stain  is  nearly 
unstained,  with  a  number  of  round  dark  blue  spots  against  a 
faintly  stained  background,  representing  the  basophilic  granulations. 

The  relative  number  of  these  different  varieties  of  white  corpuscles 
is  estimated  by  means  of  the  differential  count.  The  physician  should 
write  down  the  list  of  the  different  cells,  and  then  count  the  corpuscles 
in  the  stained  specimen,  making  a  mark  after  each  variety  of  cell. 


PLATE  XV. 


Culex. 
(Resting  Position.) 


Anopheles. 


Anopheles. 
(Resting  Position.) 


Leitz  Oil  Inimers.  Viz,  Ocular  No.  3. 


1.  Normal  Hed  Corpuscles. 

2.  Haenmtoblasts  or  Nucleated  Red 
Corpuscles: 

a.  Normoblasts. 

b.  Mcgaloblasts. 

3.  Microcytes. 

4.  Poikilocytos. 

5.  Lymphocytes 
nuclear. 

Lar^e  Mononuclear, 
a.  Transitional. 
Polynucloar  Neutrophiles. 

8.  Poly  nuclear  Eosinophiles: 
a.  Dwarf  Eosinophile. 

9.  Myelocytes: 

a.  Neutrophilic. 

b.  Eosinophilic. 


Small     Mono- 


Laboratory  Diagnosis  121 

At  least  250  white  corpuscles  should  be  counted,  and  the  number 
of  each  variety  should  be  reduced  to  a  percentage  of  the  total  number 
counted.  The  number  of  any  normoblasts  or  megaloblasts  seen 
during  the  count  should  be  noted  and  recorded,  hut  should  not  he 
included  in  the  total  of  the  count,  nor  expressed  in  figures  of  percentages. 
A  specimen  of  the  method  of  making  and  of  recording  a  differential 
blood  count  is  shown  in  the  following  tables: 

Table  13 
Method  of  Making  Differential  Blood  Count 
Polynuclearneutrophiles..    WlMrtHMftUrHlfHirHirWItilMlHllHJ 

rHlMrHltHlWIltiirHllHlMlHifliilHlfHIrao 

B^Miiies rHlfHimilHllHItHlfHIlHirHlltUlHIl 

WllHllUlIHllHimiflUrHlM  110 

Eosinophiles ||  2 

Myelocytes ^.    [|}  8 

250- 
Normoblasts, |||  j 

Megaloblasts.....,, [j|j    |  6 

130  no  2  8 

X  100  =  52%  X  100  =  44%  xioo=.8%  X  100=3.2% 

250  250  250  250 

Table  14 

Method  of  Recording  Results  of  a  Specimen 

Examination  of  the  Stained  Specimen 

DIFFERENTIAL  COUNT  OF  250  WHITE  CORPUSCLES 

Polynuclear  neutrophiles 52. 0% 

Basophiles 44 . 0% 

Eosinophiles o .  8.% 

Myelocytes 3 . 2% 

100,0% 

The  red  corpuscles  showed  slight  poikilocytosis,  and  moderate  variation  in  size,  ma- 
krocytes  predominating.  There  was  marked  achromia,  some  stippling,  and  some  poly- 
chromatophilia.     During  the  count  were  seen — 

Normoblasts  3 
Megaloblasts  6 

The  blood  platelets  appeared  normal,  and  no  parasites  were  seen. 

Peculiarities  of  the  Differential  Count  in  Early  Life. — 
The  variations  in  the  percentages  of  the  dift'erent  kinds  of  leucocytes 
in  the  blood  of  infants  and  young  children,  according  to  the  age  of 
the  child,  is  most  clearly  demonstrated  by  means  of  chart  3. 


122  Disease  in  Early  Life 

It  will  be  seen  from  the  chart  and  from  the  figures  giving  the  total 
leucocytosis  at  birth  and  in  the  subsequent  periods  of  childhood, 
that  in  the  first  day  of  Hfe  polynuclear  leucocytosis  exists  which 
decHnes  rapidly  during  the  next  nine  days,  and  then  very  gradually 
until  the  sixth  month,  when  it  begins  to  mount,  and  at  the  end  of  the 
sixth  year  has  almost  reached  the  adult  level.  The  lymphocytes,  or 
small  mononuclear  leucocytes,  are,  on  the  other  hand,  at  their  mini- 
mum at  birth,  and  in  the  subsequent  ten  days  increase  with  about 
the  same  rapidity  as  the  polynuclears  decline  in  numbers.  They 
reach  their  maximum  about  the  sixth  month  and  then  gradually 
decline  to  the  sixth  year,  while  the  polynuclears  are  proportionately 
increasing.  The  chart  also  shows  clearly  that  the  lymphocytosis  so 
characteristic  of  the  early  months  of  life  is  almost  wholly  dependent 
upon  an  increase  In  the  lymphocytes  or  small  mononuclear  cells, 
the  large  mononuclear  and  transitional  leucocytes  being  but  httle 
changed.  The  eosinophiles  show  a  count  somewhat  higher  than  in 
adults,  ranging  from  two  to  six  or  even  eight  per  cent.  Their  pres- 
ence in  such  proportions  in  early  childhood  is,  therefore,  of  less 
significance  than  in  later  life. 

Peculiarities  of  the  Blood  Picture  in  Disease  in  Early 
Life. — It  is  recognized  that  all  the  signs  by  which  sickness  is  shown 
in  the  blood  of  adults  are  exaggerated  in  that  of  children.  Their 
blood  is  much  more  sensitive  to  the  action  of  adverse  influences, 
such  as  poor  air,  improper  hygienic  surroundings,  improper  food, 
and  numerous  other  causes,  and  anemia  is  much  more  easily  induced. 
This  is  especially  noticeable  in  the  impoverishment  of  the  blood 
which  follows  gastro-enteric  disease.  Not  only  is  a  condition  of 
anemia  acquired  by  these  influences,  but  the  development  of  the 
blood  may  be  retarded.  In  this  class  of  cases  the  blood  of  a  child 
three  or  four  years  old  may  show  no  higher  development  than  that 
of  a  healthy  infant  in  the  second  year. 

Again,  the  erythrocytes  under  certain  morbid  conditions  may 
revert  to  an  earlier  type.  The  function  of  the  bone  marrow  in  infancy 
is  chiefly  occupied  in  the  production  of  the  erythrocytes.  As  the 
marrow  still  has  at  birth  many  of  its  fetal  characteristics,  any  strain 
put  upon  it  by  disease  makes  it  much  more  Ukely  to  revert  to  its 
fetal  function,  and,  therefore,  to  manufacture  and  pour  out  into 
the  circulation  the  cells  which  are  characteristic  of  that  period.  The 
presence  of  nucleated  red  cells,  myelocytes  and  eosinophiles  in 
infancy  and  early  childhood  are,  therefore,  of  less  significance 
than  in  later  life.  Opinions  differ  as  to  the  time  at  which  the  haema- 
toblasts  disappear  in  the  normal  blood  of  infants.  They  may  be 
present  in  small  numbers  during  the  first  week,  but  after  that  their 
presence  is  abnormal.  In  diseased  conditions  in  infancy  they  appear 
with  much  less  provocation  than  in  older  children  and  adults. 


Laboratory  Diagnosis 


123 


Chart  3 

showing  approximately  the  relative  proportions  of  the  leucocytes 
from  birth  to  six  years. 

(ADAPTED  FROM  CHARTS  BY  CARSTANJe'n.) 


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In  the  secondary  anemia  due  to  a  large  number  of  diseased  con- 
ditions, a  diminution  in  the  number  of  red  cells  as  well  as  of  hemo- 
globin is  more  common  in  infancy  and  early  childhood  than  later. 
The  chloro-anemia  (chlorosis)  type,  with  lower  hemoglobin  in  pro- 
portion to  the  red  count,  is  not  so  common  in  infancy.  It  should 
also  be  remembered  that  in  all  diseased  conditions,  variations  in  the 
size  and  shape  of  the  red  cells  are  much  more  easily  produced  in 
infancy  and  early  childhood,  than  later. 


124  Disease  in  Early  Lite 

The  white  corpuscles  are  affected  in  a  temporary  or  permanent 
manner  by  many  physiological  and  pathological  conditions  in  the 
body  at  large  as  well  as  in  the  blood-forming  organs.  The  most 
common  change  from  the  normal  is  that  of  leucocytosis.  Leucocy- 
tosis  was  originally  described  by  Ehrlich  as  the  presence  in  the  blood 
of  a  greater  number  of  white  cells  than  normal  for  the  individual, 
or  a  relatively  increased  number  of  any  variety  of  white  cells,  with 
or  without  an  increase  in  the  total  number  of  leucocytes.  Cabot 
has  restricted  the  term  leucocytosis  to  an  increase  of  leucocytes  in 
which  the  polynuclear  cells  predominate,  and  uses  the  terms  lympho- 
cytosis and  eosinophilia  to  describe  a  relative  increase  of  the  lympho- 
cytes and  eosinophils .  Physiologically,  we  find  a  leucocytosis  after 
meals,  often  called  digestive  leucocytosis.  It  is  at  its  height  about 
two  hours  after  a  meal,  when  the  number  of  leucocytes  may  be 
increased  by  33  1/3  per  cent,  of  the  normal  number.  Pathologically, 
a  leucocytosis  accompanies  a  considerable  number  of  diseases,  and 
seems  in  a  general  way  to  depend  upon  two  factors,  the  severity  of 
the  infection  and  the  amount  of  resistance  in  the  individual.  We 
find  a  pronounced  leucocytosis  in  most  fevers  and  in  most  septic 
processes.  In  these  cases  the  increase  is  almost  wholly  composed  of 
the  polynuclear  neutrophiles,  which  may  make  up  from  90  to  98  per 
cent,  of  the  entire  leucocyte  count.  The  leucocytosis  does  not  depend 
on  the  degree  of  fever,  does  not  always  occur  with  it,  and  conversely 
inflammatory  leucocytosis  may  appear  before  the  fever. 

The  diseases  which  generally  show  a  leucocytosis  are  pneumonia, 
pericarditis,  endocarditis,  pleuritis,  erysipelas,  acute  rheumatism, 
purulent  meningitis,  pharyngitis,  diphtheria,  septicemia,  osteomyelitis, 
scarlet  fever,  variola,  tonsillitis,  bronchitis,  peritonitis,  acute  nephritis, 
certain  gastro-enteric  infections,  some  profound  anemias  whether 
primary  or  secondary,  leukemia,  hemorrhage,  malignant  new  growths, 
abscess  of  any  kind,  including  appendicitis,  and  many  skin  diseases. 

The  diseases  in  which  the  leucocytes  are  approximately  normal  are 
malaria,  measles  (after  the  appearance  of  the  efflorescence),  typhoid 
fever,  pulmonary  tuberculosis  (unless  there  is  a  secondary  infec- 
tion of  other  bacteria),  rubella,  and  most  cases  of  epidemic  in- 
fluenza. In  tubercular  meningitis  and  peritonitis,  leucocytosis  may 
or  may  not  be  present.  Comparing  these  two  lists  it  will  be  seen 
that  there  are  instances  in  which  the  leucocyte  count  may  be  of  great 
importance  to  the  physician  in  making  a  differential  diagnosis. 

The  diagnostic  value  of  leucocytosis  in  early  life  is  usually  stated 
to  be  approximately  the  same  as  in  adult  life.  In  my  experience, 
the  value  of  the  white  count  in  diagnosis  is  not  so  great  in  infancy 
and  childhood.  Exceptions  to  the  ordinary  rules  appear  to  be  more 
numerous. 

In  diseased  conditions  in  infancy  and  early  childhood  affecting  the 


Laboratory  Diagnosis  125 

blood,  myelocytes  appear  more  often  than  in  later  life.  They  are 
usually  to  be  found  in  all  the  severe  secondary  anemias  of  infancy. 
There  are  certain  diseases  in  which  there  is  an  alteration  in  the 
differential  count  of  the  white  cells.  The  lymphocytes  are  increased 
in  pertussis,  syphilis,  and  in  leukemia.  An  increase  in  the  eosino- 
philes  is  seen  regularly  in  leukemia,  asthma,  with  certain  intestinal 
parasites,  and  in  some  forms  of  chronic  skin  disease.  In  infancy  and 
early  childhood  an  increase  in  eosinophiles  is  not  uncommon  in  sec- 
ondary anemia,  and  the  count  may  show  ten  per  cent,  without  any 
very  obvious  cause. 

THE  FECES. — The  examination  of  the  feces  is  in  infancy  the 
most  important  of  all  the  laboratory  methods  of  diagnosis.  In  older 
children  it  is  important,  but  is  not  necessarily  a  matter  of  routine. 

The  stools  are  examined  macroscopically  and  microscopically. 

The  Macroscopic  Examination  should  include  first  an  observa- 
tion of  the  frequency  and  size  of  the  dejecta,  and  of  their  consistency, 
and  form.  The  color,  odor,  and  reaction  should  be  noted.  Abnormal 
constituents  to  be  looked  for  are  curds,  mucus,  blood,  pus,  membrane, 
masses  of  undigested  food,  and  intestinal  parasites. 

Frequency  and  Size. — The  normal  number  of  stools  in  the  breast- 
fed infant  is  three  or  four  daily.  In  the  bottle-fed,  the  daily  number 
is  less,  varying  from  one  to  three  or  four.  A  certain  amount  of  con- 
stipation is  a  normal  condition  in  bottle-fed  infants  who  are  otherwise 
doing  well.  The  size  of  the  stools  varies  with  the  frequency.  Ab- 
normally small  stools  suggest  relative  starvation.  Increase  in  the 
frequency  of  the  stools  suggests  irritation  of  the  intestinal  mucosa, 
such  as  occurs  in  various  forms  of  indigestion  and  infection. 

Consistency  antd  Form. — The  normal  stool  of  the  breast-fed  infant 
is  of  a  soft  mushy  consistency.  In  infants  fed  on  cow's  milk,  the 
stools  are  of  firmer  consistency,  and  may  even  be  formed.  Increase 
in  consistency  is  seen  in  constipation.  Loose  stools  suggest  irritation 
of  the  intestinal  mucosa,  with  increased  peristalsis. 

Color. — In  observing  the  color  of  the  stools,  it  must  be  remem- 
bered that  the  surface  of  the  fecal  mass  is  easily  discolored  by  con- 
tact with  the  air,  and  the  center  should  be  used  as  a  basis  for  descrip- 
tion. 

The  color  should  be  recorded  as  yellow,  white,  brown,  green,  or 
black.     The  significance  of  the  various  colors  in  infancy  is  as  follows: 

Yellow  stools  are  seen  in  breast-fed  and  bottle-fed  infants  who 
are  doing  well.  In  the  breast-fed  the  normal  color  is  a  golden  yellow. 
In  infants  who  are  thriving  on  cow's  milk  mixtures,  the  color  is  very 
often  lighter  yellow,  probably  because  some  of  the  bilirubin  is  con- 
verted into  hydrobiHrubin,  or  because  there  is  a  slight  excess  of 
unabsorbed  protein. 


126  Disease  in  Early  Life 

Brown  stools  are  not  abnormal,  or  a  sign  that  an  infant  is  not 
thriving.  Various  shades  of  brown  are  seen  when  the  amount  of 
protein  in  the  food  is  high  in  proportion  to  the  fat.  This  often  occurs 
when  infants  are  being  fed  on  skimmed  milk  or  whey,  or  on  lactic 
acid  milk  or  albumen  milk.  Brown  stools  are  also  normal  when 
maltose  is  substituted  for  lactose  as  the  extra  sugar  added  to  cow's 
milk  modifications.  When  the  infant  begins  to  take  a  more  varied 
diet,  containing  starch,  beef  juice,  or  broth,  the  stools  assume  a  brown- 
ish color. 

Gray  stools  are  abnormal.  A  gray  color  may  be  due  to  the  pres- 
ence in  the  stool  of  a  large  amount  of  fat.  While  not  normal,  a  gray 
color  is  not  in  itself  an  indication  that  the  amount  of  fat  should  be 
reduced.     A  gray  color  is  also  seen  when  bile  is  absent  or  insufficient. 

Green  is  the  most  common  abnormal  color.  The  shade  may  vary 
from  a  Hght  grass  green,  to  a  dark  green.  The  darker  the  green, 
the  greater  the  pathological  significance.  A  stool  which  changes 
from  yellow  to  green  after  exposure  to  the  air  is  not  abnormal.  The 
abnormal  green  color  is  due  to  the  oxygenation  of  bilirubin  into  bili- 
verdin,  and  this  apparently  may  take  place  when  the  stool  is  either 
excessively  alkaHne,  or  excessively  acid,  or  as  a  result  of  various  forms 
of  bacterial  activity.  Green  stools  are  seen  in  all  forms  of  indigestion, 
and  are  not  characteristic  of  any  one  type.  They  are  particularly 
common  in  acute  stages  of  indigestion  from  fat  or  carbohydrate, 
and  in  indigestion  with  fermentation. 

White  stools  are  due  to  the  presence  of  an  excessive  quantity  of 
undigested  fat  in  the  form  of  soaps.  They  may  be  soft  or  hard. 
White  stools  are  always  a  sign  that  the  digestion  and  absorption  of 
fat  is  not  normal,  but  are  not  necessarily  an  indication  for  cutting 
down  the  fat  in  the  food. 

Black  stools  are  usually  due  to  the  giving  of  bismuth,  or  iron,  or  to 
the  presence  of  blood. 

Odor. — The  odor  of  the  stools  depends  on  the  composition  of  the 
food,  on  the  completeness  of  digestion  and  absorption,  and  on  the 
degree  and  variety  of  bacterial  activity.  The  normal  stool  has  a 
sour  or  aromatic  odor.  In  fat  indigestion  the  odor  is  that  of  butyric 
or  lactic  acid.  In  carbohydrate  indigestion  the  odor  of  lactic  or 
acetic  acid  predominates.  Excessive  protein,  even  when  not  causing 
indigestion,  produces  a  cheesy  or  fecal  odor.  A  peculiar  musty  odor 
is  also  suggestive  of  a  relative  excess  of  protein  in  the  food.  A  very 
foul  or  putrefactive  odor  is  seen  in  some  cases  of  acute  indigestion 
with  fermentation,  and  of  infection  of  the  intestine. 

Reaction. — The  reaction  of  the  normal  stool  is  slightly  acid.  When 
the  relative  quantities  of  the  fat  and  protein  are  well  balanced,  it 
is  probable  that  the  normal  slight  acidity  of  the  stools  is  maintained 


Laboratory  Diagnosis  127 

by  the  fermentation  of  the  carbohydrate  residue  which  is  not  ab- 
sorbed, and  that  Nature  designs  that  there  shall  be  an  excess  of 
carbohydrate  to  maintain  a  normal  condition  of  the  intestinal  flora, 
and  the  normal  chemical  reaction.  When  the  unabsorbed  carbo- 
hydrate residue  is  in  excess,  it  is  never  excreted  as  such,  but  under- 
goes fermentation,  and  consequently  the  acidity  of  the  stools  may  be 
increased.  When  unabsorbed  fat  is  in  excess,  there  is  increased  forma- 
tion of  the  fatty  acids,  and  the  acidity  of  the  stools  may  also  be  in- 
creased. A  relative  excess  of  protein  will  cause  increased  activity 
of  the  proteolytic  bacteria  whose  products  are  alkaline,  and  may 
cause  an  alkaline  stool,  which  is  not  necessarily  pathological.  An 
excessively  acid  stool,  therefore,  is  seen  in  carbohydrate  indigestion, 
and  in  the  acute  exacerbations  of  fat  indigestion.  An  alkahne  stool 
means  only  a  relative  excess  of  protein  in  the  food  in  the  majority  of 
cases,  and  has  no  pathological  significance.  It  is,  however,  occa- 
sionally seen  in  cases  of  indigestion  with  fermentation  due  to  an 
excessive  activity  of  bacteria  of  the  putrefactive  group. 

Curds. — There  are  two  kinds  of  curds  found  in  the  stools  of  an 
infant.  One  is  primarily  composed  of  casein,  the  other  of  fat  com- 
bined with  sodium  and  potassium  in  the  form  of  soaps.  The  casein 
curds  are  larger,  varying  in  size  from  that  of  a  bean  to  that  of  a  pea- 
nut, and  are  white  or  yellowish-white  in  color.  They  are  tough, 
cannot  be  broken  up  by  pressure,  are  insoluble  in  ether,  and  when 
placed  in  formaHn  become  very  hard.  The  fat  curds  are  smaller 
varying  in  size  from  that  of  a  pinhead  to  that  of  a  pea,  and  are  white, 
yellow,  or  green  in  color  according  to  the  color  of  the  stool.  They 
are  soft,  can  be  broken  up  by  pressure,  are  soluble  in  ether  when 
acidified,  and  are  unaffected  by  formahn. 

Casein  curds  suggest  indigestion  from  a  relative  excess  of  protein. 
Fatty  curds  always  suggest  indigestion  from  a  relative  excess  of  fat. 
Not  only  that,  but  fatty  curds  suggest  a  degree  or  stage  of  fat  indiges- 
tion which  is  more  serious  than  that  characterized  simply  by  an 
excess  of  fat  in  the  stools  in  the  form  of  soaps,  and  is  usually  an  indi- 
cation for  dietetic  treatment. 

Mucus. — Mucus  is  present  in  most  normal  stools,  but  in  amounts 
which  can  only  be  detected  by  microscopic  examination.  In  the 
majority  of  abnormal  stools,  an  excess  of  mucus  is  present,  and  an 
amount  visible  macroscopically  is  always  pathological.  Undigested 
starch  may  be  mistaken  for  mucus,  but  is  distinguished  by  the  fact 
that  it  is  stained  blue  with  iodine,  and  shows  a  definite  structure 
(starch  granules)  under  the  microscope,  whereas  mucus  is  not  stained, 
and  shows  no  evidence  of  structure. 

An  excess  of  mucus  in  the  stools  is  caused  by  any  condition  which 
irritates  the  intestinal  mucous  membrane.     It  may  be  seen  in  all 


128  Disease  in  Early  Life 

forms  of  indigestion.  A  very  great  excess  of  mucus,  or  a  stool  com- 
posed mainly  of  mucus,  especially  if  there  is  also  blood,  suggests 
infectious  diarrhea  or  intussusception. 

Blood  in  the  stools  is  always  pathological.  It  can  usually  be  easily 
recognized  on  macroscopic  examination,  but  sometimes  it  is  necessary 
to  prove  that  the  appearance  seen  in  the  stools  is  certainly  blood. 

The  guaiac  test  is  the  best  for  blood.  The  reagent  consists  of  ten 
drops  of  freshly  prepared  tincture  of  guaiac  and  thirty  drops  of  hydro- 
gen peroxide.  To  lo  c.c.  of  stool  or  other  suspected  material  in  a 
test  tube  add  2  c.c.  of  glacial  acetic  acid  and  15  c.c.  of  ether.  Insert 
a  cork,  and  invert  several  times.  When  the  ether  has  separated, 
decant  it,  and  add  the  ethereal  solution  to  the  reagent.  A  blue 
color  indicates  the  presence  of  blood. 

When  blood  appears  as  a  spot  or  streak  of  fresh  blood  on  the  out- 
side of  a  hard  stool,  it  indicates  some  slight  local  lesion  about  the 
anus,  usually  a  fissure,  rather  than  a  hemorrhoid.  When  the  blood 
is  mixed  with  mucus,  but  not  homogeneously,  occurring  usually  in 
spots  or  streaks,  it  means  some  form  of  ileo-colitis,  the  most  common 
being  that  seen  in  infectious  diarrhea.  When  blood  is  homogene- 
ously mixed  with  mucus,  it  suggests  intussusception.  When  blood 
occurs  without  excess  of  mucus,  usually  as  a  tarry  mass,  it  suggests 
gastro-intestinal  hemorrhage  from  some  other  cause. 

Pus,  visible  macroscopically,  means  a  severe  inflammatory  condi- 
tion of  the  intestinal  tract. 

Membrane  is  rarely  seen,  because  the  patients  in  whom  mem- 
branous colitis  is  found  post-mortem,  usually  die  before  the  membrane 
appears  in  the  stools.     It  means  a  very  severe  inflammation. 

Undigested  Masses  of  food  can  sometimes  be  recognized  macro- 
scopically.    Their  significance  is  obvious. 

Intestinal  Parasites. ^ — The  commonest  in  children  in  northern 
latitudes  are  round  worms  (ascaris)  and  pin-worms  (oxyuris).  Seg- 
ments of  the  several  varieties  of  tape  worms  (taenia)  are  seen  at 
times,  usually  the  beef  worm  (taenia  saginata).  Hook  worms  (un- 
cinaria)  are  found  in  some  localities.  Other  parasites,  including  the 
amoebae,  are  rare. 

Bile  Pigment  is  a  normal  constituent  of  the  stools.  Its  absence 
is  sometimes  of  great  diagnostic  significance.  The  test  is  as  follows: 
Mix  about  one-quarter  of  the  stool  thoroughly  with  100  c.c.  of  a 
concentrated  solution  of  corrosive  sublimate,  and  set  aside  in  a  cov- 
ered glass  dish  for  twenty-four  hours.  All  particles  containing  hydro- 
bilirubin  will  have  a  red  color,  while  those  containing  bilirubin  will 
be  green. 


Laboratory  Diagnosis  129 

Microscopic  Examination  of  the  Stools. — This  is  of  the  first 
importance  in  all  the  nutritional  disturbances  of  infancy.  In  older 
children  it  is  often  of  diagnostic  value,  but  need  not  be  made  a  rou- 
tine measure.  The  examination  is  divided  into  three  parts  as  fol- 
lows: (i)  examination  of  the  fresh  specimen;  (2)  microchemical 
examination  for  fat;  (3)  microchemical  examination  for  starch. 
The  feces  should  be  thoroughly  mixed  in  preparation  for  these 
examinations,  and  if  hard,  should  be  rubbed  together  with  a  Uttle 
water. 

Examination  of  the  Fresh  Specimen. — A  portion  of  the  stool 
is  placed  on  a  slide,  covered  with  a  cover  glass  and  put  under  the 
microscope.  This  reveals  undigested  meat  fibres,  and  such  patho- 
logical elements  as  pus,  blood,  eggs  of  parasites,  and  so  forth. 

Microchemical  Examination  for  Fat. — A  portion  of  the  stool 
is  spread  on  a  glass  slide,  and  mixed  with  a  saturated  alcoholic  solu- 
tion of  Sudan  III.  It  is  then  covered  with  another  sHde  (a  sUde  is 
better  than  a  cover  glass)  and  put  under  the  microscope.  Neutral 
fat  drops,  and  fatty  acid  crystals,  stain  red,  while  soaps  do  not  stain. 
Next  a  drop  or  two  of  glacial  acetic  acid  is  thoroughly  mixed  with 
the  contents  of  the  sHde.  It  is  better  to  add  the  acid  by  removing 
the  top  shde,  rather  than  by  letting  it  run  under  the  edge.  The  top 
sHde  is  reapplied,  and  the  sHde  is  held  over  the  Bunsen  flame  until 
it  begins  to  bubble.  This  converts  the  soaps  into  neutral  fat  and 
fatty  acids,  which  appear  under  the  microscope  as  large  stained 
drops.  The  amount  of  fat  in  the  form  of  soap  is  estimated  from  the 
number  of  these  drops. 

If  the  stain  with  Sudan  III  before  the  addition  of  acetic  acid  shows 
fat,  it  can  be  determined  whether  it  is  neutral  fat  or  fatty  acid,  by 
staining  another  specimen  with  a  dilute  solution  of  carbolfuchsin  (i 
part  carbolfuchsin  to  4  parts  of  water).  With  this  solution  neutral 
fat  does  not  stain,  fatty  acids  stain  a  deep  red,  and  soaps  stain  a 
dull  rose-red. 

In  estimating  the  quantity  of  fat  in  the  form  of  soap,  it  must  be 
remembered  that  under  normal  conditions  all  the  fat  ingested  is  not 
absorbed,  and  that  a  certain  quantity  of  soaps  in  the  stools  is  normal. 
The  difliculty  in  the  microchemical  examination  of  the  stools  for  fat 
lies  in  determining  what  quantity  shall  be  termed  an  excess.  With  the 
technique  described  above  the  only  standard  for  estimating  the 
amount  of  fat  is  the  number  and  size  of  the  fat-droplets  in  the  micro- 
scopic field,  after  boiHng  with  acetic  acid.  The  standard  is  much 
influenced  by  variations  in  the  technique,  depending  on  the  quan- 
tity of  feces  taken,  the  amount  of  its  dilution,  the  length  of  the  boil- 
ing, and  on  variations  in  the  rapidity  and  completeness  with  which 
soaps  made  with  different  alkaline  bases  are  broken  up.  Every  physi- 
9 


130  Disease  in  Early  Lite 

cian  must  establish  his  own  standard,  by  adopting  a  uniform  tech- 
nique, noting  the  results  obtained  with  numerous  babies  fed  on 
different  quantities  of  fat,  and  comparing  these  results  with  the 
macroscopic  appearance  of  the  stools.  The  following  may  prove 
useful  as  a  suggestion: 

1.  Fat  droplets  crowding  field  and  running  together. . . .  =  large  excess 

2.  Fat  droplets  numerous  in  every  field =  moderate  excess 

3.  Fat  droplets  few  in  every  field ^  slight  excess 

4.  Fat  droplets  not  in  every  field =  no  excess 

The  presence  of  neutral  fat  indicates  an  imperfect  digestion  of 
the  fat,  and  usually,  but  not  always,  means  that  the  fat  in  the  food 
is  in  sufficient  relative  excess  to  cause  nutritional  disturbance.  The 
presence  of  an  excess  of  fat  in  the  form  of  soaps  indicates  that  the 
fat  is  normally  spHt  by  the  digestive  ferments,  but  that  it  is  not 
normally  absorbed,  the  quantity  in  the  food  being  in  excess  in  pro- 
portion to  the  power  of  assimilation.  Such  an  excess  may  or  may 
not  cause  nutritional  disturbance. 

MiCROCHEMiCAL  EXAMINATION  FOR  Starch. — This  of  course,  is 
carried  out  only  with  the  stools  of  infants  and  young  children  who 
are  taking  foods  containing  starch.  The  staining  reagent  is  Lugol's 
solution  (iodine  2;  potassium  iodide  4;  distilled  water  100).  The 
stools  are  placed  on  a  slide,  mixed  with  this  solution,  and  examined 
under  the  microscope.  The  starch  granules  stain  blue  or  violet. 
There  are  certain  microorganisms  which  also  stain  blue  with  this 
solution,  and  the  presence  of  these  so-called  iodophilic  bacteria  sug- 
gests a  disturbance  of  carbohydrate  digestion. 

The  presence  of  starch  in  the  stools  indicates  that  the  quantity 
of  starch  in  the  food  is  too  great  for  the  digestive  power,  and  that 
any  symptoms  of  indigestion  present  are  probably  caused  in  part  at 
least  by  this  excess. 

Bacteriologic  Examination. — In  the  present  stage  of  our  knowl- 
edge, this  is  very  unsatisfactory.  Our  knowledge  of  intestinal  bac- 
teriology is  very  limited,  and  in  comparison  with  what  remains  un- 
known, hardly  a  scratch  has  been  made  upon  the  surface  of  this  very 
complicated  subject.  We  know  that  bacteria,  and  bacterial  activity, 
play  a  very  important  part  in  gastro-intestinal  disturbances,  but  this 
subject  is  still  so  complicated  that  it  has  not  afforded  any  very  valu- 
able methods  of  laboratory  diagnosis.  There  are  certain  special 
tests,  such  as  those  for  the  gas  bacillus  and  the  dysentery  bacillus, 
which  will  be  described  under  infectious  diarrhoea.  For  further 
methods,  clinicians  must  wait  for  the  research  workers,  who  are 
making  very  slow  and  discouraging  progress  at  the  present  writing. 

THE  CEREBROSPINAL  FLUID.— In  the  routine  macroscopic 
examination  of  the  cerebrospinal  fluid,  the  points  to  be  recorded  are 


Laboratory  Diagnosis  131 

the  quantity  ohtamed,  the  pressure,  the  turbidity,  and  the  presence  or 
absence  of  fibrin  formation.  The  pressure  is  estimated  by  the  rate 
and  force  of  the  flow  through  the  luniibar  puncture  needle.  Normally 
the  fluid  falls  from  the  needle  in  discrete  drops,  with  an  appreciable 
pause  between  each  drop.  If  the  fluid  drops  more  rapidly,  but  still 
in  discrete  drops,  the  pressure  may  be  recorded  as  shghtly  increased. 
If  the  fluid  runs  in  a  continuous  stream,  the  pressure  is  increased, 
and  if  it  spurts  from  the  needle,  it  is  markedly  increased.  The  pres- 
sure may  be  accurately  measured  by  special  apparatus,  but  this  is 
not  necessary  in  ordinary  cHnical  work. 

With  regard  to  turbidity,  the  fluid  is  recorded  as  clear,  faintly 
cloudy,  opalescent,  turbid,  or  purulent.  In  a  purulent  fluid,  a  dis- 
tinct zone  of  pus  settles  at  the  bottom  of  the  test  tube. 

Fibrin  Formation  is  shown  by  the  appearance  in  the  fluid  of  a  gos- 
samer-like web  on  standing. 

In  the  routine  microscopic  examination  of  the  cerebrospinal  fluid, 
the  points  to  be  noted  are  the  cell  count,  the  character  of  the  cells, 
and  the  presence  or  absence  of  bacteria. 

Cell  Count. — The  estimation  of  the  cell  count  should  be  made 
first,  when  the  fluid  is  as  fresh  as  possible  and  before  the  fibrin  clot 
has  had  time  to  form.  The  fluid  in  the  test  tube  is  thoroughly  shaken 
for  one  or  two  minutes.  The  Toma-Zeiss  white  blood  counter  is 
used,  not  as  in  blood  examination  to  obtain  a  dilution,  but  simply 
for  purposes  of  mixing.  Glacial  acetic  acid  is  drawn  into  the  blood 
counter  to  about  the  0.5  mark,  accuracy  not  being  essential,  as  the 
only  purpose  of  the  acid  is  to  dissolve  any  red  corpuscles  which  may 
be  present,  and  to  make  the  nuclei  of  the  white  cells  stand  out  sharply. 
The  counter  is  then  inserted  into  the  cerebrospinal  fluid,  which  is  drawn 
up  until  the  counter  is  filled.  It  is  then  thoroughly  shaken  for  sev- 
eral minutes,  and  a  drop  of  its  contents  is  placed  on  the  Toma-Zeiss 
slide  in  the  same  way  as  for  a  blood  examination.  All  the  cells  in- 
cluded within  the  ruled  field  are  counted.  Ten  counts  are  made 
in  this  way,  and  the  sum  of  these  ten  counts  gives  the  cell  count  or 
number  of  cells  in  one  cubic  millimeter  of  cerebrospinal  fluid. 

The  error  caused  by  the  slight  dilution  with  acetic  acid  is  so  small 
that  it  may  be  neglected.  If,  however,  the  fluid  is  contaminated 
with  blood,  a  variable  error  is  introduced  depending  upom  the  pro- 
portion of  blood  present.  If  the  fluid  is  only  slightly  blood-stained, 
the  error  is  negligible,  but  if  there  is  evidence  that  considerable  blood 
has  entered  the  fluid,  the  results  of  the  cell  count  are  useless  for 
diagnostic  purposes.  The  normal  cell  count  is  not  over  ten  cells  per 
cubic  millimeter,  which  is  only  an  average  of  one  cell  to  each  ruled  field. 

Cyto-Dl\gnosis. — During  the  performance  of  the  cell  count,  the 
physician  can  usually  sufficiently  differentiate  the  mononuclear  from 


132  Disease  in  Early  Life 

the  polynuclear  cells  to  form  an  estimate  of  the  predominating  type. 
For  greater  accuracy  the  differential  count  may  be  made  upon  the 
stained  specimen.  A  cover  glass  preparation  can  be  stained  with 
Wright's  modification  of  the  Leischman  stain,  or  the  differential  count 
can  be  made  on  a  cover  glass  which  has  been  stained  for  bacteria. 
The  results  are  recorded  in  percentages  of  polynuclears  and  mono- 
nuclears. 

Bacteriologic  Examination. — While  it  is  advisable  to  take  cul- 
tures from  all  suspected  specimens  of  cerebrospinal  fluid,  the  results 
of  the  examination  of  cover  glass  preparations  are  more  valuable  for 
diagnostic  purposes  than  are  the  results  of  culture,  because  all  of 
the  bacteria  commonly  encountered  in  the  cerebrospinal  fluid  can 
be  found  in  cover  glass  preparations,  whereas  the  diplococcus  intra- 
cellularis  is  of  uncertain  growth  in  cultures.  The  best  method  of 
making  a  cover  glass  preparation  is  to  wait  until  the  fibrin  clot  has 
formed.  This  is  removed  with  a  platinum  loop  and  is  thoroughly 
rubbed  and  kneaded  upon  the  surface  of  a  cover  glass.  If  no  fibrin 
clot  be  formed,  the  preparation  should  be  made  from  the  centri- 
fugahzed  sediment.  For  routine  examination  the  best  stain  is  Lof- 
fler's  alkaline  methylene-blue.  With  this  the  presence  and  mor- 
phology of  all  the  organisms  which  cause  meningitis  can  be  deter- 
mined, except  the  tubercle  bacillus,  which  requires  its  special  stain. 
The  diagnosis  can  usually  be  arrived  at  with  this  stain,  but  for  pur- 
poses of  completeness,  or  in  case  of  doubt  Gram's  stain  should  be 
used  on  another  slide. 

The  diplococcus  intracellularis  is  recognized  by  its  occurrence  in 
biscuit-shaped  pairs,  the  cocci  composing  a  pair  lying  side  by  side 
with  reference  to  their  long  axis.  It  is  decolorized  by  Gram's  method. 
The  pneumococcus  occurs  for  the  most  part  in  pairs,  but  sometimes 
in  short  chains ;  in  cerebrospinal  fluid  the  chains  are  rarely  more  than 
four  cells  in  length.  The  cells  composing  the  pairs  lie  end  to  end 
with  reference  to  their  long  axis.  This  organism  retains  the  Gram's 
stain.  The  streptococcus  in  the  cerebrospinal  fluid  almost  always 
forms  long  easily  recognizable  chains,  and  shows  no  tendency  to  occur 
in  pairs.  The  staphylococcus  is  recognized  by  its  typical  occurrence 
in  clumps.  Both  staphylococci  and  streptococci  retain  the  Gram 
stain.  The  bacillus  of  influenza  is  the  most  difficult  organism  to 
recognize.  Although  a  bacillus,  the  bipolar  staining  is  usually  so 
prominent  that  the  appearance  of  the  organism  suggests  a  diplococcus. 
For  this  reason  the  influenza  bacillus  is  often  mistaken  both  for  the 
diplococcus  intracellularis  and  for  the  pneumococcus.  The  bipolar  dots 
of  the  influenza  bacillus  are  smaller  than  either  of  these  two  varieties 
of  cocci.  Also  in  most  specimens,  while  many  forms  resemble  a  diplo- 
coccus, involution  forms  are  usually  present.     In  these  involution 


Laboratory  Diagnosis  133 

forms  the  morphology  is  distinctly  that  of  a  bacillus.  They  do  not 
look  like  the  typical  bipolar  forms,  and  are  often  quite  large.  As  a 
result  of  these  peculiarities,  the  impression  given  by  the  slide  is  that 
of  a  mixed  infection  of  diplococci  and  bacilli,  which  is  puzzling  unless 
the  tendency  to  the  appearance  of  involution  forms  is  remembered, 
when  the  appearances  become  an  aid  in  diagnosis.  The  bacillus  of 
influenza  is  decolorized  by  Gram's  method.  In  case  of  doubt  cultures 
should  be  made  upon  blood  agar  and  plain  agar,  as  the  influenza 
bacillus  only  grows  in  the  presence  of  hemoglobin. 

The  following  points  in  the  bacteriological  diagnosis  of  the  cere- 
brospinal fluid  are  the  results  of  a  very  wide  experience  with  cerebro- 
spinal fluids,  and  while  not  strictly  scientific,  may  prove  of  value: 
Whenever  diplococci  are  very  few  and  difficult  to  find,  the  evidence 
points  toward  the  intracellularis.  Whenever  there  are  many  organ- 
isms included  within  the  leucocytes,  the  evidence  points  toward  the 
intracellularis.  Whenever  diplococci  are  very  numerous,  although 
few  are  included  within  the  leucocytes,  the  evidence  points  toward 
the  pneumococcus. 

The  stain  for  the  tubercle  bacillus  is  precisely  the  same  as  that 
used  in  the  sputum,  urine,  and  other  suspected  materials.  Cover 
the  preparation  with  carbolfuchsin  solution  and  steam  over  a  flame 
for  thirty  seconds,  not  allowing  the  staining  solution  to  dry  on  the 
glass,  but  adding  more  stain  if  necessary.  Wash  in  water,  and  then 
decolorize  for  twenty  seconds  with  20  per  cent,  sulphuric  acid.  Wash 
in  water,  and  then  wash  in  95  per  cent,  alcohol  until  no  more  color 
will  come  out.  Wash  in  water.  Cover  the  preparation  with  Lofiier's 
methyl ene-blue  solution  for  thirty  seconds.  Wash  in  water  and 
mount.  Under  the  microscope  the  tubercle  bacilli  are  bright  red, 
while  the  nuclei  of  the  cells  are  blue. 

The  finding  of  the  tubercle  bacillus  in  the  cerebrospinal  fluid  is 
often  very  difficult.  If  the  organism  is  not  found  in  a  preparation 
made  from  the  fibrin  clot,  it  is  advisable  to  digest  the  clot  in  artificial 
gastric  juice,  and  then  centrifugalize  thoroughly.  The  fluid  from  the 
bottom  of  the  centrifugal  tube  is  put  upon  the  slide  and  allowed  to 
dry  in  air. 

The  following  table  shows  the  characteristics  of  cerebrospinal 
fluid  in  some  of  the  most  common  conditions,  in  which  they  are  of 
diagnostic  significance.  The  term  meningismus  as  used  in  the  table 
refers  to  a  condition  of  meningeal  irritation  from  a  variety  of  causes 
without  infection. 

Special  Tests. — There  are  a  number  of  special  tests  which  can 
be  applied  to  the  cerebrospinal  fluid,  the  final  value  of  which  is  still 
under  investigation.  These  tests  depend  upon  the  fact  that  in  the  normal 
cerebrospinal  fluid  the  amount  of  protein  present  is  too  small  to  be 


134  Disease  in  Early  Lite 

recognized  by  ordinary  clinical  methods,  whereas  in  all  inflammations 
of  the  meninges  there  is  an  increase  of  protein  substances,  among 
which  the  globulin  is  most  used  in  tests.  These  tests  have  as  their 
chief  advantage  over  the  simple  routine  method  of  examination 
described  above  that  they  are  more  delicate.  Among  the  principal 
ones  are  to  be  mentioned  Nonne's  test,  Noguchi's  butyric  acid  test, 
Lange's  colloidal  gold  test,  and  Boveri's  permanganate  of  potash 
test.  The  technique  of  these  tests  is  too  complicated  for  ordinary 
clinical  use.  At  present  their  chief  place  is  in  the  research  laboratory. 
They  will  not  be  described  here,  but  the  reader  is  referred  to  recent 
literature  for  a  description  of  their  technique  and  diagnostic  value. 

EXUDATES  AND  TRANSUDATES.— The  laboratory  examina- 
tion of  effusions  into  the  pleural,  peritoneal,  and  pericardial  cavities 
is  often  an  important  diagnostic  procedure. 

Appearance. — First  note  the  appearance  of  the  fluid,  and  in  par- 
ticular whether  it  is  clear,  cloudy,  or  purulent.  The  color  of  serous 
fluids  should  be  noted,  whether  pale,  straw  color,  orange,  red,  or  bile 
stained.  The  presence  or  absence  of  fibrin  formation  should  also 
be  noted. 

Specific  Gravity. — Take  the  specific  gravity  of  all  serous  fluids. 
This  is  important  in  distinguishing  between  exudates  and  transu- 
dates. 

Albumin.- — The  fluid  should  be  tested  for  albumin,  and  the  per 
cent,  of  albumin  present  should  be  estimated  by  some  quantitative 
method.  It  can  be  estimated  roughly  from  the  amount  of  sediment 
in  the  heat  test  as  described  for  the  urine.  A  more  accurate  estimate 
may  be  made  with  Esbach's  graduated  tubes. 

The  Sediment. — The  sediment  should  be  examined  microscop- 
ically, and  the  character  of  the  cells  and  other  bodies  should  be  noted. 

Cyto-Diagnosis. — Place  the  fluid  in  clean  centrifuge  tubes  and 
centrifugalize  thoroughly.  Pour  off  the  supernatant  fluid  by  invert- 
ing the  tube,  and  stir  up  the  sediment  in  the  remaining  drops  of  fluid 
with  the  platinum  loop.  Spread  a  drop  of  this  mixture  on  a  cover 
glass  and  allow  it  to  dry  spontaneously  without  heat.  Stain  with 
a  fluid  made  up  of  Wright's  modification  of  Leischman  stain  three 
parts,  and  pure  methyl  alcohol  one  part.  The  sHde  is  stained  by  the 
method  described  for  the  examination  of  the  stained  specimen  of 
blood.  The  same  method  as  for  blood  is  used  in  making  a  differential 
count  of  the  cells. 

Bacteriological  Examination. — Bacteria  are  stained  by  the 
solution  used  for  cyto-diagnosis.  In  case  of  doubt  as  to  their  mor- 
phology, another  sHde  may  be  stained  with  Loffler's  methylene-blue 
solution.     Further  evidence  as  to  the  type  of  microorganism  present 


Laboratory  Diagnosis 


135 


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136  Disease  in  Early  Life 

may  be  gained  by  staining  with  Gram's  method  as  described  for  the 
sputmn.  The  method  of  staining  for  tubercle  bacillus  is  the  same  as 
that  used  for  all  suspected  tuberculous  material.  Cultures  should 
be  taken  from  all  exudates. 

Differential  Diagnosis. — The  following  points  in  the  examina- 
tion of  serous  fluid  serve  to  distinguish  exudates  from  transudates. 

Table  i6 

Distinction  Between  Exudates  and  Transudates 

EXUDATES        TRANSUDATES 

Specific  gravity 1016-1026  1008-10x8 

Albumin 2-6%  .  2-2% 

Fibrin Present  Absent 

Sediment Leucocytes  Epithelial  cells 

The  sediment  of  all  exudates  except  the  tuberculous  is  composed 
chiefly  of  polynuclear  leucocytes.  Tuberculous  exudates  show  a 
much  higher  proportion  of  mononuclear  cells,  which  may  predomin- 
ate.    Bacilli  are  often  difflcult  to  demonstrate  in  tuberculous  effusions. 

EXAMINATION  OF  THE  VAGINAL  DISCHARGE.— This  is 

very  important,  particularly  in  infancy.  Vaginal  discharge  is  not 
uncommon  in  early  life,  and  in  a  large  proportion  of  cases  it  is  due 
to  the  gonococcus.  So  common  is  gonorrheal  infection  in  female 
infants,  and  so  contagious  is  it  that  an  examination  of  the  vaginal 
discharge  should  be  made  as  a  routine  measure  with  every  infant 
admitted  to  a  hospital,  whether  or  not  macroscopic  discharge  be 
visible.  The  material  is  obtained  by  gentle  swabbing  of  the  vulva, 
and  is  spread  on  a  cover  glass,  dried,  fixed  in  the  flame,  and  stained. 
The  following  method  of  staining  should  be  employed:  Cover  for 
one  minute  with  Stirling's  gentian  \dolet,  or  with  anilin  gentian  violet. 
Wash  in  water.  Apply  Gram's  iodine  and  iodide  of  potash  solution 
for  thirty  seconds.  Wash  in  water.  Wash  in  95  per  cent,  alcohol 
until  the  blue  color  ceases  to  come  out.  Wash  in  water.  Counter- 
stain  with  a  solution  of  carbolfuchsin  diluted  i  to  8,  without  heat, 
or  with  a  saturated  aqueous  solution  of  Bismark  brown.  Wash  in 
water  and  mount.  All  diplococci  within  the  leucocytes  which  have 
not  retained  the  blue  stain,  but  have  taken  the  red  or  brown  counter- 
stain  are  to  be  considered  gonococci. 

EXAMINATION  OF  THE  SPUTUIM.— The  examination  of  the 
sputum  does  not  hold  so  important  a  place  among  diagnostic  pro- 
cedures in  infancy  and  early  childhood  as  it  does  in  adult  life.  Infants 
and  young  children  habitually  swallow  their  sputum,  and  it  is  conse- 
quently much  more  difficult  to  obtain  a  specimen  of  sputum  for  exam- 
ination. Not  only  that,  but  the  evidence  obtained  from  the  sputum 
examination  in  children  is  not  so  valuable  as  in  adults.  The  forms 
of  tuberculosis  which  aft'ect  young  children  are  not  the  phthisis  of 


Laboratory  Diagnosis  137 

adults,  and  do  not  show  tubercle  bacilli  in  the  sputum  with  anything 
like  the  same  frequency  as  does  phthisis.  The  bacterial  picture 
shown  by  the  sputum  of  even  lobar  pneumonia  in  children  is  not  so 
clear  cut  and  definite  as  it  is  in  adults.  For  these  reasons  the  exam- 
ination of  the  sputum  cannot  be  called  a  necessary  routine  measure. 
In  the  pulmonary  affections  of  early  life  it  is  often  however  of  diag- 
nostic value,  and  should  be  employed  in  all  cases  of  doubtful  diag- 
nosis. The  specimen  of  sputum  for  examination  can  best  be  obtained 
from  the  pharynx.  The  examination  of  the  swallowed  sputum  ex- 
pelled in  the  vomitus  or  obtained  from  the  stomach,  is  not  satisfactory. 
In  obtaining  sputum,  cough  should  be  excited  by  irritation  of  the 
pharynx.  This  causes  sputum  to  be  brought  into  view  and  it  can 
be  caught  upon  a  cotton  swab.  It  is  easy  to  obtain  sputum  in  this 
way,  but  the  value  of  the  examination  is  lessened  by  the  fact  that 
the  physician  can  never  be  sure  that  the  sputum  comes  from  the 
lungs  and  is  not  sputum  which  has  trickled  down  from  the  naso-pharynx. 

Macroscopic  examination  is  of  little  diagnostic  value  in  children. 
The  sputum  should  be  stained  separately  for  the  tubercle  bacillus 
and  for  other  organisms. 

Stain  for  the  Tubercle  Bacillus. — In  preparing  a  cover  glass 
for  the  tubercle  bacillus  stain,  select  if  possible  purulent  or  cheesy 
particles.  These  can  be  removed  by  means  of  a  stiff  platinum  wire, 
and  should  be  smeared  as  thoroughly  as  possible  upon  a  cover  glass. 
The  preparation  held  in  the  forceps  is  dried  over  the  flame  of  a  Bunsen 
burner  and  fixed  by  being  passed  three  times  through  the  flame. 
Cover  the  preparation  with  carbolfuchsin  solution  and  steam  over 
the  flame  for  half  a  minute,  adding  more  stain  if  necessary,  to  prevent 
the  staining  solution  from  drying  on  the  surface  of  the  glass.  Wash 
in  water.  Decolorize  for  twenty  seconds  in  20  per  cent,  sulphuric 
acid.  Wash  in  water.  Wash  in  95  per  cent,  alcohol  until  no  more 
color  will  come  out.  Wash  in  water.  Cover  the  preparation  with 
Loffler's  methylene-blue  solution  for  thirty  seconds.  Wash  in  water 
and  mount.  Tubercle  bacilli  are  stained  bright  red,  nuclei  and 
other  bacteria  being  blue. 

Routine  Stain  for  Other  Organisms. — The  cover  glass  should 
be  smeared  with  sputum  as  thinly  as  possible.  It  is  dried  and  fixed 
in  the  flame  by  the  usual  method.  Cover  with  Stirling's  gentian 
violet  or  anilin  gentian  violet,  and  heat  over  the  flame  until  the  stain 
just  steams.  Wash  in  water.  Cover  with  Gram's  iodine  and  iodide 
of  potash  solution  for  thirty  seconds.  Wash  in  95  per  cent,  alcohol 
until  the  blue  color  ceases  to  come  out.  Stain  with  Loffler's  methy- 
lene-blue solution,  heating  to  the  steaming  point.  Wash  in  water, 
dry,  and  mount. 

By  this  method  of  staining  the  pneumococcus  will  be  stained  blue- 


138  Disease  in  Early  Life 

black,  and  its  characteristic  morphology  can  usually  be  recognized. 
The  capsule  will  not  stain,  but  the  various  special  methods  for  stain- 
ing capsules  do  not  give  constant  results  and  are  not  necessary  in 
routine  examination.  The  influenza  bacillus  will  be  stained  blue,  and 
the  fact  that  it  does  not  take  the  Gram  stain  is  usually  apparent.  The 
influenza  bacillus  is  the  smallest  organism  found  in  sputum.  Owing 
to  the  bipolar  staining  it  usually  gives  the  impression  of  a  very  small 
diplococcus.  In  case  of  doubt  as  to  the  results  of  the  Gram  stain, 
a  second  preparation  may  be  stained  by  Gram's  method,  and  counter- 
stained  with  Bismark  brown  instead  of  Lofiier's  blue.  The  bacillus 
mucosus  capsulatus  can  generally  be  recognized  by  its  morphology. 
If  doubt  exists,  if  a  specimen  is  stained  with  carbolfuchsin,  the  cap- 
sules will  show.  There  are  various  methods  of  staining  the  sputum 
which  give  prettier  preparations,  but  they  are  rather  complicated 
for  routine  use. 

EXAMINATION  OF  THE  GASTRIC  CONTENTS.— This  pro- 
cedure is  less  valuable  as  a  m.eans  of  diagnosis  in  the  diseases  of 
early  Hfe  than  in  those  of  adult  life.  Organic  disease  of  the  stomach 
is  so  rare  in  childhood  that  it  hardly  enters  into  consideration. 
In  the  various  functional  disturbances  so  common  in  infancy  and 
childhood,  the  examination  of  the  gastric  contents  throws  little 
light  upon  the  diagnosis.  The  whole  etiology  and  classification  of 
gastro-intestinal  disease  is  entirely  different  in  infancy  and  childhood 
from  that  of  adult  life,  and  calls  for  entirely  different  methods  of 
diagnosis.  There  are  almost  no  conditions  met  with  in  children  in 
which  there  is  an  absence  of  free  hydrochloric  acid. 

Blood. — The  most  common  test  called  for  in  examining  the 
vomitus  or  gastric  contents  of  infants  and  children  is  that  for  blood. 
The  guaiac  test  should  be  used  as  described  under  the  examination 
of  the  feces. 

Free  Hydrochloric  Acid. — This  may  be  tested  for  by  the  same 
tests  as  are  used  in  adults,  such  as  Gunzburg's,  Topfer's  and  oo 
tropaeolin.  These  tests  are  so  rarely  required  in  children  that  they 
will  not  be  described  here,  and  the  reader  is  referred  to  the  various 
adult  text-books. 

WIDAL  REACTION  FOR  TYPHOID.— This  procedure  has  the 
same  diagnostic  significance  in  children  as  in  adults. 

Collect  three  or  four  drops  of  blood  in  a  small  test  tube,  and  let  it 
stand  until  the  serum  is  exuded.  When  dried  blood  is  employed,  it  must 
be  mixed  with  a  few  drops  of  water,  this  mixture  taking  the  place  of 
serum.  In  making  the  test,  use  a  bouillon  culture  of  t>phoid  bacillus 
from  twelve  to  twenty-four  hours  old.  Examine  a  drop  of  this  cul- 
ture under  the  microscope  in  order  to  make  sure  that  the  bacilli  are 
unclumped  and  in  active  motion.     Mix  nine  drops  of  the  typhoid 


4. 


\ 


M 


\ 


■  is'^'-m^ 


Fig.  4c — Scarifying  for  von  Pirquet  tuberculin  lest 


Laboratory  Diagnosis  139 

culture  with  one  drop  of  blood  serum  upon  one  end  of  the  slide. 
Upon  the  other  end  of  the  slide  make  a  i  to  50  dilution  by  mixing 
one  drop  of  the  i  to  10  dilution  with  four  drops  of  water.  Drops  of 
equal  size  are  obtained  by  using  a  platinum  loop.  Cover  both  the 
I  to  10  and  I  to  50  dilutions  with  cover  glasses.  Make  controls  in  the 
same  way  except  that  the  blood  serum  is  omitted.  The  serum  re- 
action is  regarded  as  positive  when  before  the  end  of  one  hour  there 
is  complete  clumping  of  the  bacilli,  and  an  absolute  cessation  of  motil- 
ity in  both  dilutions,  the  controls  remaining  unclumped.  The  re- 
action is  regarded  as  suggestive  but  not  positive  when  only  the  i  to 
10  dilution  is  agglutinated.  A  positive  reaction  is  diagnostic  evidence 
of  typhoid  infection  or  antityphoid  vaccination. 

THE  VON  PIRQUET  REACTION  FOR  TUBERCULOSIS.— 

The  tuberculin  reaction  and  its  theory,  the  various  methods  of  apply- 
ing it,  and  its  diagnostic  value,  are  discussed  in  detail  under  tuber- 
culosis. For  routine  use,  von  Pirquet's  cutaneous  test  is  the  one 
to  be  employed.  Wash  the  skin  of  the  forearm  by  rubbing  with 
alcohol  and  ether,  and  apply  two  small  drops  of  Koch's  old  tuberculin 
undiluted,  about  10  cm.  apart.  A  scarifier  resembling  a  tiny  chisel 
which  has  been  sterilized  by  heating,  is  used  for  the  inoculation. 
Apply  this  first  to  the  skiu  between  the  tuberculin  drops  and  rotate 
with  a  boring  motion.  Repeat  this  procedure  on  the  skin  through 
each  of  the  tuberculin  drops.  The  boring  must  be  sufficient  to  remove 
only  the  superficial  layers  of  the  skin.  The  blood-vessels  of  the 
deeper  layers  should  show  through,  but  blood  should  not  be  drawn. 
As  a  precaution  against  rubbing,  cover  the  site  of  the  inoculation 
with  a  piece  of  sterile  gauze.  A  positive  reaction  is  shown  by  the 
appearance  of  reddened  areolae  about  the  two  points  of  the  inocula- 
tion, while  no  reddening  is  seen  about  the  control.  The  reaction 
usually  begins  within  twenty-four  hours,  reaches  its  height  during 
the  second  twenty-four  hours,  and  slowly  fades  in  one  or  two  days. 
If  the  areola  is  less  than  5  millimeters  in  diameter,  the  reaction  should 
be  considered  as  doubtful  rather  than  positive.  In  my  experience, 
however,  with  infants,  based  oh  the  results  of  autopsies,  a  doubtful  re- 
action usually  means  tuberculosis. 

In  infants  and  children  a  negative  reaction  has  no  diagnostic  sig- 
nificance. A  positive  reaction  means  tuberculosis  in  the  great  rna- 
jority  of  cases. 

CUTANEOUS   TEST  FOR   FOOD   IDIOSYNCRASIES.— The 

technique  of  this  test  is  exactly  the  same  as  that  of  the  cutaneous 
tuberculous  test,  except  that  a  small  bit  of  the  suspected  food  sub- 
stance is  used  in  place  of  the  tubercuhn.  Food  idiosyncrasies  are  not 
rare  in  infancy.  The  idiosyncrasy  most  commonly  shown  is  against 
some  protein  food  substance,  such  as  lactalbumen,  egg  albumen,  or 


140 


Disease  in  Early  Life 


casein.  Whenever  there  is  a  history  of  symptoms  following  the  in- 
gestion of  some  particular  food  substance,  a  cutaneous  test  should 
be  employed.  A  positive  reaction  indicates  that  the  symptoms  are 
caused  by  a  food  idiosyncrasy  toward  the  special  substance. 

WASSERMANN  REACTION  FOR  SYPHILIS.— The  comple- 
ment fixation  test  of  Wassermann  is  of  the  greatest  value  in  the 
diagnosis  of  syphihs  in  early  life.  The  technique  of  the  test  is  alto- 
gether too  complicated  for  routine  use,  and  the  test  can  only  be 
satisfactorily  made  by  one  trained  in  its  performance.     There  are 

Fig.  41 


Obtaining  blood  for  the  Wassermann  reaction  from  the  longitudinal  sinus  of  an  infant 

however  a  certain  number  of  laboratories  where  this  test  is  being 
habitually  made,  and  in  every  case  of  suspected  SA^hilis,  a  specimen 
of  blood  should  be  sent  to  a  Wassermann  laboratory  for  examination. 
About  10  c.c.  of  blood  should  be  required  for  the  test,  and  it  is  difh- 
cult  to  obtain  so  much  blood  from  infants  by  the  ordinary  methods. 
The  best  method  of  obtaining  blood  from  infants  for  examination 
is  to  take  advantage  of  the  open  fontanelle.  The  longitudinal  sinus 
which  lies  immediately  under  the  anterior  fontanelle  is  a  very  large 
vein  which  can  be  very  easily  reached.  A  small  Luer  syringe  and 
hypodermic  needle  are   sterilized,   and   the  skin  over  the  anterior 


Laboratory  Diagnosis 


141 


fontanelle  is  cleansed.  A  small  area  may  be  shaved  if  there  is  much 
hair.  The  needle  attached  to  the  syringe  is  entered  at  the  posterior 
angle  of  the  fontanelle  exactly  in  the  median  line.  The  needle  passes 
through  the  skin  and  dura  with  a  perceptible  sense  of  suddenly 
lessened  resistance.  The  piston  of  the  syringe  is  then  drawn,  and 
the  syringe  immediately  fills  with  blood.  This  method  of  obtaining 
the  blood  is  greatly  preferable  to  the  gashing  of  the  ear  or  heel,  which 
was  necessary  for  obtaining  enough  blood  for  the  Wassermann  re- 
action. My  assistant  at  the  Infants'  Hospital  recently  obtained  in 
this  way  specimens  of  blood  from  ten  babies  in  eleven  minutes.  The 
specimen  in  a  sterile  test  tube  should  be  tightly  corked  before  being 
sent  to  the  Wassermann  laboratory. 

Fig.  42 


Injecting  diphtheria  toxin  for  the  Schick  reaction 

THE  SCHICK  REACTION  TEST  FOR  IMMUNITY  AGAINST 
DIPHTHERIA. — This  test  is  mainly  useful  in  hospital  practice, 
but  it  is  sometimes  useful  in  private  practice  in  determining  whether 
a  prophylactic  dose  of  diphtheria  antitoxin  is  indicated  in  children 
with  whom  there  has  been  exposure  or  suspicion  of  exposure  to  diph- 
theria. Its  value  as  a  reHable  test  of  immunity  has  been  confirmed 
by  the  majority  of  recent  investigations,  although  it  is  perhaps  not 
finally  proved. 


142  Disease  in  Early  Life 

Diphtheria  toxin  is  used  for  the  test.  The  minimum  lethal  does 
of  the  toxin  for  a  guinea  pig  weighing  300  grams  must  be  known. 
This  is  so  diluted  that  o.i  ex.  of  fluid  contains  1/50  of  this  minimum 
lethal  dose.  This  is  injected  with  a  very  small  needle,  not  under 
the  skin  but  into  the  skin.  If  the  injection  is  properly  made,  it 
should  cause  a  small  raised  white  looking  spot.  If  the  reaction  is 
negative,  there  is  no  further  discoloration  at  the  site  of  the  injection. 
If  the  reaction  is  positive,  the  area  within  twenty-four  hours  becomes 
reddened  and  slightly  edematous.  This  passes  off  in  forty-eight 
hours,  leaving  a  brownish  pigmentation.  A  positive  reaction  indi- 
cates that  the  individual  has  less  than  1/30  of  a  unit  of  natural  anti- 
toxin in  I  c.c.  of  blood,  and  such  individuals  are  to  be  considered 
susceptible  to  diphtheria.  A  negative  reaction  indicates  that  the 
individual  has  more  than  1/30  of  a  unit  of  natural  antitoxin  in  i  c.c. 
of  blood,  and  is  immune  to  diphtheria.  The  reaction  has  also  a 
diagnostic  value,  because  children  sick  with  diphtheria  show  a  posi- 
tive reaction  before  antitoxin  is  given. 

It  has  been  shown  that  most  newly  born  infants  are  protected  by 
natural  antitoxin,  and  that  about  57  per  cent,  of  children  in  the  first 
year  of  life,  and  37  per  cent  of  children  between  two  and  five  years, 
are  immune. 

THROAT  CULTURES.— The  chief  purpose  for  which  cultures 
are  taken  from  the  throat  is  in  the  diagnosis  of  diphtheria.  A  cer- 
tain amaunt  of  evidence  can  also  be  gained  as  to  other  infecting  organ- 
isms, not  only  by  the  examination  of  cultures  from  the  throat,  but 
also  from  examination  of  cover  glass  preparations  made  from  the 
material  obtained  by  swabbing. 

Cultures  should  be  taken  from  all  cases  in  which  the  examination 
of  the  throat  shows  the  presence  of  exudate  or  membrane.  The  swab 
should  be  appHed  to  the  edge  of  the  membrane  and  should  be  drawn 
rather  forcibly  across  the  suspected  area.  The  swab  is  then  rubbed 
upon  the  surface  of  a  blood  serum  culture  medium.  The  culture 
should  be  incubated  for  twelve  hours,  and  then  examined  by  means 
of  cover  glass  preparations.  The  best  routine  stain  is  Loffler's  methy- 
lene-blue  solution.  The  diphtheria  bacillus  is  recognized  by  its 
pecuHar  morphology. 

BLOOD  CULTURES.— In  a  great  number  of  infectious  conditions 
in  infancy  and  childhood,  the  bacteria  enter  the  blood  stream.  Cul- 
tures from  the  blood  are  often  very  valuable  in  diagnosis,  but  this 
method  is  not  employed  as  much  as  it  should  be  on  account  of  the 
supposed  difficulty  of  obtaining  blood  from  infants  and  young  chil- 
dren under  proper  sterile  conditions.  The  introduction  of  the  method 
of  obtaining  blood  from  infants  from  the  longitudinal  sinus  has  very 
much  simphfied  the  technique  of  blood  cultures.     Exactly  the  same 


Laboratory  Diagnosis  143 

procedure  is  employed  as  in  obtaining  blood  for  the  Wassermann 
reaction.  In  older  children  with  closed  fontanelles,  the  blood  can 
be  obtained  from  one  of  the  veins  of  the  arm,  which  can  be  made  to 
stand  out  by  a  tourniquette.  The  blood  obtained  should  be  inoculated 
upon  the  various  culture  media,  according  to  the  resources  of  the 
bacteriological  laboratory.  For  routine  use,  inoculations  should  be 
made  in  bouillon  and  upon  blood  agar.  The  special  method  of  exam- 
ining blood  cultures  for  typhoid  will  be  described  under  that  disease. 

PHENOLSULPHONEPHTHALEIN  TEST  FOR  RENAL 
FUNCTION. — Within  the  last  few  years  various  methods  of  testing 
renal  function  have  been  introduced.  These  tests  have  appeared 
to  be  of  notable  diagnostic  value  in  many  diseased  conditions  of  the 
kidney.  The  most  useful  single  test  among  them  is  that  with  phenol- 
sulphonephthalein. 

Under  aseptic  precautions,  the  patient  is  given  an  intramuscular 
injection  of  i  c.c.  of  a  sterilized  solution  containing  6  mgm.  of  phenol- 
sulphonephthalein.  Any  urine  passed  during  the  next  two  hours  is 
saved,  and  at  the  end  of  that  time  the  patient  is  made  to  empty  his 
bladder,  or  is  catheterized.  All  the  urine  collected  in  this  way  is 
made  definitely  aklaline,  and  is  diluted  to  make  i  liter.  A  standard 
solution  of  alkaline  reaction,  containing  6  mgm.  of  phenolsulphone- 
phthalein  in  i  liter,  is  made  up.  Some  of  the  urine  dilution  is  put 
in  a  test  tube,  and  a  series  of  test  tubes  of  equal  diameter  are  made  up 
containing  various  dilutions  of  the  standard  solution.  In  this  way, 
by  colorimetric  readings,  the  amount  of  the  drug  excreted  in  the  urine 
can  be  estimated.  More  accurate  results  can  of  course  be  obtained 
by  .the  use  of  Antenreieth-Konigsberger  or  other  type  of  colorimeter. 

With  normal  renal  function,  6o  to  8o  per  cent,  of  the  drug  should 
be  excreted  in  two  hours.  If  the  amount  is  less  than  this,  a  disturb- 
ance of  renal  function  is  indicated,  and  the  degree  of  the  disturbance 
is  measured  by  the  amount  of  the  decrease. 

DIFFERENTIAL  DIAGNOSIS 

When  all  the  evidence  which  can  be  obtained  from  the  history, 
physical  examination,  and  laboratory  investigation  is  at  hand,  the 
physician  is  confronted  with  the  problem  of  diagnosis.  In  certain 
eases,  there  is  something  in  the  evidence  which  is  so  positively  diag- 
nostic, that  a  decision  can  be  arrived  at  at  once.  Care  must  be 
taken,  however,  not  to  base  a  positive  diagnosis  upon  symptoms  or 
signs  whose  presence  or  absence  is  not  absolutely  diagnostic.  Care 
must  be  taken  also  not  to  overlook  the  possibility  of  more  than  one 
pathological   condition. 

In  other  cases,  the  evidence  obtained  suggests  only  a  number  of 
possibiHties,  without  anything  positively  diagnostic  of  any  one  of 


144  Disease  of  Early  Life 

them.  In  these  cases  a  differential  diagnosis  must  be  made  through 
a  careful  weighing  of  the  evidence.  In  making  a  differential  diag- 
nosis, it  is  unnecessary  to  consider  every  possibihty  that  could  go 
with  every  symptom.  The  best  method  of  arriving  at  a  conclusion 
is  for  the  physician  to  select  the  most  prominent  symptom  or  group 
of  associated  symptoms,  which  demand  explanation.  He  should 
then  make  a  written  or  mental  Hst  of  all  the  conditions  which  could 
produce  this  group  of  symptoms.  He  should  then  consider  how  many 
of  these  possibilities  can  be  positively  excluded  by  the  different  kinds 
of  diagnostic  evidence  at  hand  or  obtainable.  If  more  than  one  pos- 
sibihty be  left,  he  should  arrange  these  alternatives  in  the  order  of 
their  probabihty  as  suggested  by  the  evidence. 

Care  must  be  taken  in  excluding  possibihties  in  diagnosis.  A  dis- 
tinction must  be  drawn  between  cHnical  evidence  which  positively 
excludes  a  certain  condition,  and  chnical  evidence  which  is  only 
against  a  certain  condition.  The  latter  class  of  evidence  can  only  be 
used  in  arranging  possibihties  in  the  order  of  their  probabihty. 

When  an  opinion  is  formed  as  to  the  diagnosis,  the  evidence  should 
again  be  reviewed  with  reference  to  whether  the  diagnosis  is  adequate 
to  account  for  all  the  symptoms  and  signs  of  disease  which  are  present. 
If  it  is  not  adequate,  the  possibihty  of  two  things  must  be  considered; 
one  is  that  some  false  step  in  the  reasoning  has  led  to  a  mistaken 
diagnosis;  the  other  is  that  more  than  one  diseased  condition  may 
be  present.  The  chnical  evidence  must  be  reconsidered  with  a  \dew 
to  setthng  these  alternatives. 

The  abihty  to  make  an  accurate  diagnosis  ui  early  hfe  depends 
upon  the  weighing  of  the  clinical  evidence.  If  the  standards  used  in 
diagnosing  disease  in  adults  are  used,  many  mistaken  diagnoses  will 
be  made  with  children.  The  physician  must  be  thoroughly  famihar 
with  the  anatomy,  physiology,  and  development  of  the  normal  child, 
and  with  all  the  pecuharities  of  the  pathology,  symptomatology,  and 
diagnostic  methods  of  childhood. 


IV.     PROGNOSIS  IN  EARLY  LIFE 

The  most  important  factor  in  the  prognosis  of  disease  in  early 
hfe  is  the  age  of  the  patient.  The  general  rule  is  that  the  younger 
the  patient,  the  worse  is  the  prognosis  in  all  the  diseases  of  childhood. 
It  is  for  this  reason  that  the  mortaHty  of  the  first  year  of  life  is  so 
high,  and  that  it  shows  a  progressive  diminution  throughout  the  re- 
maining years  of  childhood.  I  shall  not  take  time  here  to  review 
the  much  discussed  question  of  infant  mortality,  nor  to  show  in 
detail  the  relative  frequency  of  the  different  causes  of  death  at  the 
different  ages. 

The  causes  of  the  high  mortality  of  infancy  may  be  summarized 
as  follows:  In  the  first  place,  there  is  the  feeble  resistance  of  the 
infantile  organism  in  general  to  all  the  external  causes  of  disease. 
This  feebleness  of  resistance  is  shown  not  only  against  those  external 
causes  which  produce  disturbance  of  function,  but  also  against  in- 
fections. In  the  second  place,  the  feeble  resistance  of  the  undeveloped 
organism  may  be  increased  both  by  inherited  conditions  and  by  con- 
genital faults  of  development.  A  third  cause  is  the  prevailing  ignor- 
ance as  to  the  hygienic  demands  of  the  young  organism  and  the 
conditions  which  are  essential  to  its  proper  health  and  growth. 

In  the  first  year  of  Hfe,  gastro-intestinal  conditions  rank  first  as 
a  cause  of  death,  with  acute  respiratory  tract  infection  second,  con- 
genital malnutrition  third,  and  other  acute  infections  fourth.  In 
the  second  year,  diseases  of  the  gastro-intestinal  tract  still  hold  first 
place.  It  is  difficult  to  draw  a  distinction  between  acute  infections 
of  the  respiratory  tract  and  the  acute  contagious  diseases,  because 
death  so  often  occurs  when  the  former  is  a  complication  of  the  latter. 
Measles,  diphtheria,  and  pertussis,  with  their  pulmonary  complica- 
tions appear  to  hold  second  place,  but  in  my  opinion,  the  statistical 
figures  of  infant  mortality  show  altogether  too  low  a  proportion  for 
acute  tuberculosis  and  tuberculous  meningitis.  After  the  second 
year,  the  acute  infections  rank  ahead  of  all  other  causes. 

In  considering  questions  of  prognosis,  it  must  be  remembered  that 
in  general,  infants  and  young  children  succumb  easily  to  acute  con- 
ditions. They  also  show  much  more  markedly  the  effects  of  chronic 
functional  disturbance.  On  the  other  hand,  numerous  diseases 
accompanied  by  organic  lesions  in  early  Hfe,  show  a  remarkable 
possibility  of  complete  recovery  as  compared  with  adult  life.  Many 
organic  conditions  which  in  adults  would  be  permanent  can  in  chil- 
dren be  "outgrown,"  provided  that  the  patient  can  be  placed  under 
proper  hygienic  surroundings.  This  power  of  recovery  from  organic 
10 


146  Disease  in  Early  Life 

disease  is  due  to  the  peculiarly  rapid  metabolism  of  childhood.  There 
are  also  a  certain  number  of  infectious  diseases  which  are  less  severe 
in  infants  than  in  adults,  owing  to  certain  peculiarities  of  the  anatomy 
of  early  life. 

In  children,  it  is  lack  of  development  and  peculiarities  of  func- 
tional resistance  which  form  the  unknown  factor  in  prognosis,  just 
as  in  adults  it  is  the  effects  of  all  abuses,  such  as  alcohol,  and  vari- 
ous forms  of  wear  and  tear  which  constitute  the  unknown  factor. 
The  prognosis  in  any  diseased  condition  can  only  be  estimated  from 
a  knowledge  of  the  peculiarities  of  the  particular  disease  in  early 
life,  and  from  an  estimate  of  the  constitutional  peculiarities  of  the 
individual  patient.  In  children  of  apparently  robust  constitution 
and  normal  development,  the  prognosis  in  those  acute  diseases  which 
do  not  tend  inevitably  to  a  fatal  ending,  is  fairly  good.  In  children 
of  poor  development  and  poor  constitutional  resistance,  the  prognosis 
is  proportionately  bad.  In  chronic  functional  disturbances,  the 
prognosis  depends  largely  upon  the  length  of  time  which  the  dis- 
ease has  existed,  and  the  degree  of  malnutrition  and  lowered  resistance 
which  has  been  brought  about. 

In  giving  a  prognosis  in  early  life,  the  physician  must  remember 
two  things:  One  is  the  liabiUty  in  infancy  to  sudden  and  unexpected 
death  from  various  unsuspected  causes.  The  other  is  the  liability 
of  infants  and  children  to  develop  unexpected  comphcations.  The 
prognosis  of  the  various  diseased  conditions  as  compared  with  the 
same  conditions  in  adults,  will  be  discussed  in  detail  in  the  consid- 
eration of  the  various  diseases. 


V.  TREATMENT 

GENERAL  PRINCIPLES 

The  one  great  principle  in  the  modern  treatment  of  disease  is  re- 
moval of  the  cause.  This  is  particularly  applicable  to  the  diseases 
of  infancy  and  childhood.  A  very  large  group  of  the  disturbances 
to  which  children  are  particularly  hable  belong  in  the  class  of  func- 
tional disturbances  from  multiple  external  causes,  and  tend  toward 
spontaneous  recovery  as  soon  as  the  causes  are  found  and  removed. 
Not  only  are  these  diseases  curable  through  timely  removal  of  the 
causes,  but  they  are  still  more  easily  preventable.  A  second  large 
group  is  represented  by  the  infections,  in  which  the  cause,  while  not 
removable  after  infection  has  taken  place,  is  nevertheless  also  often 
preventable. 

Prophylaxis  is  therefore  the  most  important  department  of  the 
treatment  of  disease  in  early  life.  There  is  no  more  promising  field 
in  the  whole  of  medicine  than  the  prevention  of  disease  in  childhood. 
The  fundamental  principles  in  preventive  medicine  are  two  in  num- 
ber: (i)  The  removal  of  the  external  factors  in  hygiene  and  environ- 
ment which  interfere  with  normal  development,  and  contribute  to 
disease;  (2)  the  prevention  of  infection.  The  first  principle  can  be 
appKed  only  by  the  education  not  only  of  the  medical  profession, 
but  also  through  them  of  the  general  public,  in  the  proper  hygiene 
of  early  life.  The  second  can  be  reahzed  through  continued  study 
of  the  mechanism  of  infection  and  the  principles  of  immunity  on  the 
one  hand,  and  of  such  problems  as  disinfection,  sanitation,  and  quar- 
antine on  the  other.  In  these  last  problems  the  public  health  authori- 
ties have  their  great  field. 

When  disease  has  actually  occurred,  the  true  diagnostic  problem 
which  confronts  the  physician  is  not  the  mere  finding  of  a  name  for 
the  condition,  but  the  finding  of  the  cause.  No  name  is  of  any  value 
which  does  not  connote  all  that  is  known  of  etiology,  and  nothing 
is  worse  than  for  a  physician  to  hide  ignorance  of  etiology  and  path- 
ology under  vague  names  like  grip,  marasmus,  rheumatism,  bilious- 
ness, and  so  forth,  which  are  not  based  on  distinct  etiological  con- 
ceptions. Taking  refuge  in  names  which  have  a  definite  if  incorrect 
signification  to  the  general  public  may  satisfy  the  parents  of  our 
patients,  but  should  not  satisfy  us,  unless  we  go  further,  so  that  our 
diagnosis  suggests  all  that  is  known  of  etiology.  It  is  for  this  reason 
that  so  much  stress  is  laid  upon  etiological  factors  throughout  this 
book. 


148  Disease  in  Early  Life 

Modern  treatment  is  primarily  aimed,  not  at  the  mere  relief  of 
symptoms,  but  at  the  cause.  This  does  not  mean  that  symptomatic 
treatment  does  not  have  its  place.  It  is  obviously  our  duty  to  relieve 
symptoms  as  far  as  possible.  But  symptomatic  treatment  is  longer 
established,  better  known,  and  easier  of  application  than  is  treatment 
aimed  at  causes,  and  there  is  danger  that  we  may  lose  sight  of  the 
latter  in  self-satisfaction  at  our  ability  to  apply  the  former. 

SPECIAL  INDICATIONS  IN  EARLY  LIFE 

The  peculiarities  of  disease  in  childhood  which  modify  the  treat- 
ment are  chiefly  due  to  the  incompleteness  of  anatomical  and  func- 
tional development  at  that  period  of  life.  Three  groups  of  conditions 
besides  the  acute  infections  are  particularly  common  in  childhood. 
These  are  (i)  functional  disturbance  of  the  digestive  system,  (2) 
functional  disturbance  of  the  nervous  system,  and  (3)  functional 
disturbance  of  the  general  nutrition  and  metabolism.  Even  in  other 
diseases,  such  as  the  infections,  these  three  varieties  of  functional 
disturbance  are  particularly  common  as  manifestations.  The  treat- 
ment required  by  these  three  kinds  of  disturbance  is  mainly  hygienic 
and  dietetic,  and  consequently  these  forms  of  treatment  are  rela- 
tively of  the  first  importance  in  childhood. 

On  the  other  hand,  the  great  variety  of  subjective  symptoms  which 
demand  treatment  in  the  adult  are  much  less  common  in  childhood. 
Consequently  symptomatic  treatment  directed  at  such  manifesta- 
tions plays  a  relatively  unimportant  part.  Moreover,  certain  im- 
portant systems  of  the  body  suffer  less  from  disease  in  children  than 
in  adults.  The  chief  example  of  this  difference  is  the  heartland 
circulatory  system,  which  is  most  damaged  by  the  wear  and  tear 
of  the  adult  life,  and  consequently  often  calls  for  symptomatic  treat- 
ment, but  which  is  relatively  competent  to  combat  disease  in  child- 
hood. Drug  treatment  plays  its  most  important  part  in  combatting 
subjective  symptoms  and  circulatory  disturbance.  The  role  of 
drugs  is  consequently  relatively  smaller  in  early  life. 

Treatment  may  be  divided  into  specific,  hygienic,  dietetic,  and 
symptomatic. 

SPECIFIC  TREATMENT 

In  the  infectious  diseases,  the  first  aim  in  therapeutics  has  always 
been  to  find  some  remedial  agent  which  will  act  directly  on  the  cause 
of  the  disease.  This  effort  has  led  to  much  study  of  the  mechanism 
of  transmission  and  infection,  of  the  mechanism  of  defence,  and 
of  the  comphcated  problems  of  immunity.  It  has  been  finally  de- 
monstrated that  the  human  organism  has  various  means  of  defence 
against  the  occurrence  of  infection,  and  various  means  of  combatting 
infection  when  once  it  has  occurred.    These  natural  methods  of 


Specific  Treatment  149 

combatting  infection  are  the  cause  of  the  self-Hmited  character  of 
many  acute  diseases,  and  of  the  fact  that  in  most  infections  there  is 
a  natural  tendency  toward  eventual  recovery. 

The  first  object  of  treatment  is  to  hasten  recovery — to  overcome 
the  infection  as  quickly  as  possible.  In  the  search  for  therapeutic 
measures  which  are  specific,  that  is  which  act  directly  on  the  par- 
ticular microorganism  causing  the  disease,  attention  was  first  turned 
to  drugs — chemical  agents  which  when  introduced  into  the  body,  would 
kill  or  injure  the  microorganisms  or  prevent  their  development.  The 
idea  of  the  possible  value  of  drugs  in  combatting  infection  was  based 
on  the  fact  that  many  drugs  have  a  demonstrable  pharmacological 
action,  modifying  and  influencing  various  bodily  functions  in  vari- 
ous ways,  and  as  the  symptoms  of  infection  are  due  to  a  disturbance 
of  bodily  function,  a  drug  which  caused  the  opposite  effect,  which 
lessened  the  disturbance  of  the  function,  was  considered  of  value 
against  the  microorganism  causing  the  trouble.  It  has  been  found, 
however,  that  in-so-far  as  the  bacterial  infections  are  concerned,  there 
is  no  drug  which  can  be  safely  introduced  into  the  body  which  will  act 
directly  on  the  microorganisms  causing  the  disease,  and  that  consequently , 
there  is  no  specific  drug  therapy  for  the  diseases  caused  by  bacteria. 

It  has  been  supposed  that  the  influence  of  drugs  upon  bodily  func- 
tion might  be  utilized  in  bringing  about  recovery,  through  the  finding 
of  drugs  which  aid  the  natural  methods  of  resistance,  defence,  and 
disinfection.  A  drug  which  has  such  a  power  would  be  considered 
specific.  It  has  been  found,  however,  that  the  natural  methods  of 
recovery  from  bacterial  infections  depend  upon  much  more  compli- 
cated biological  processes  than  the  simple  physiological  functions 
which  can  be  influenced  by  drugs.  The  most  that  drugs  can  do  in 
infections  is  to  strengthen  and  support  functions  whose  disturbance 
threatens  a  fatal  ending  before  the  natural  methods  of  defence  have 
time  to  act,  or  to  aid  in  the  promotion  of  the  general  resistance  of 
the  body  against  adverse  influences.  The  action  of  drugs  in  bac- 
terial infections  is  therefore  in  no  way  specific. 

The  same  is  true  of  the  various  non-medicinal  therapeutic  measures. 
Their  r61e  is  the  relief  of  subjective  symptoms,  the  support  of  threat- 
ened function,  and  the  strengthening  of  general  resistance. 

For  a  true  specific  therapy  in  the  bacterial  infections,  we  must 
look  further.  The  study  of  the  natural  methods  of  defence,  and  of 
the  complicated  subject  of  immunity,  has  given  us  two  methods  of 
aiding  or  hastening  the  natural  methods  of  recovery.  These  are 
serum  therapy,  and  vaccine  therapy. 

SERUM  THERAPY.— This  consists  in  the  introduction  into  the 
patient's  circulation  of  the  serum  of  an  animal  which  has  been  im- 
munized by  inoculations  with  the  bacterium  causing  the  disease. 


150  Disease  in  Early  Life 

Immunological  research  has  demonstrated  that  one  of  the  methods 
of  defence  through  which  recovery  from  infection  takes  place,  is  the 
formation  in  the  blood  serum  of  the  patient  of  immune  bodies.  These 
immune  bodies  are  of  various  kinds;  some  neutralize  the  toxin  formed 
by  the  bacteria  (antitoxins),  others  kill  the  bacteria  (bactericidal 
substances),  others  prevent  the  multiplication  of  bacteria,  and  others 
injure  the  bacteria  in  such  a  way  that  they  fall  an  easy  prey  to  phago- 
cytic tissue  cells  (opsonins,  or  bacteriotropins) .  If  an  animal  be 
inoculated  with  bacteria,  or  preparations  made  from  bacteria,  under 
proper  conditions,  its  tissues  will  be  stimulated  to  the  formation  of 
immune  bodies,  which  will  be  contained  in  its  blood  serum.  The 
therapeutic  use  of  such  immune  animal  sera  is  serum  therapy. 

The  most  conspicuous  example  of  success  in  serum  therapy  is 
diphtheria.  This  success  led  to  the  hope  that  a  similar  specific  therapy 
would  be  applicable  to  all  the  infectious  diseases.  This  hope  has 
not  been  realized.  The  immune  body  in  diphtheria  is  an  antitoxin, 
and  it  has  been  found  that  only  in  infections  with  an  organism  which 
secretes  a  soluble  toxin  as  does  the  diphtheria  bacillus,  can  an  effective 
antitoxic  serum  be  obtained  through  animal  inoculation.  The  only 
other  effective  antitoxic  serum  is  that  produced  by  animal  inoculation 
with  the  bacillus  of  tetanus.  In  the  other  infections,  the  organisms 
do  not  secrete  a  soluble  toxin,  but  liberate  endotoxins,  and  the  mechan- 
ism of  immunity  is  much  more  complicated.  Hence  serum  therapy 
has  made  slow  progress. 

The  most  successful  example  of  serum  therapy  besides  diphtheria, 
is  in  epidemic  cerebrospinal  meningitis.  Immune  sera  have  been  ob- 
tained and  widely  employed  against  infection  with  the  streptococcus ^ 
the  pneumococcus,  the  bacillus  of  dysentry,  the  bacillus  of  influenza, 
and  the  tubercle  bacillus.  Most  of  these  sera  have  given  strong  lab- 
oratory evidence  of  value.  Some  of  them  have  given  some  clinical 
evidence  of  value,  but  on  the  whole,  in  these  infections,  serum 
therapy  cannot  be  said  to  have  proved  markedly  successful. 

The  reasons  for  the  failure  of  complete  success  of  serum  therapy 
against  the  infectious  diseases,  may  be  summarized  as  follows: 

1.  In  some  diseases  certainly  infectious,  the  specific  organism  has 
not  been  demonstrated.  Examples  are  scarlet  fever,  measles,  rubella, 
varicella,  mumps. 

2.  Some  diseases  cannot  be  sufficiently  reproduced  in  animals 
to  permit  the  production  of  an  immune  serum.  Examples,  typhoid 
fever,  gonococcus  infection. 

3.  In  some  diseases  immunity  depends  on  tissue  reactions  of  a 
very  complicated  nature,  in  which  the  formation  of  immune  bodies 
in  the  blood  serum  probably  plays  a  very  small  part.  Example, 
tuberculosis. 


Specific  Treatment  151 

4.  In  some  diseases  the  specific  organism  has  been  so  recentl}'  dis- 
covered, that  there  has  not  been  sufl&cient  time  to  investigate  the 
problem  of  immunity,  and  to  build  a  satisfactory  foundation  for 
serum    therapy.     Examples,    pertussis,    poliomyeloencephalitis. 

5.  In  some  infections  the  specific  organism  does  not  represent  a 
single  type,  but  includes  a  variety  of  strains,  each  with  its  particular 
immune  reaction  of  varying  complexity.  Much  time  will  be  required 
for  the  study  and  differentiation  of  these  strains  and  their  immune 
reactions,  before  an  effective  serum  therapy  will  become  practical. 
Examples  are  the  pneumococcus,  the  streptococcus,  rheumatic  fever. 

It  will  be  seen  from  the  causes  of  failure  up  to  the  present  time, 
that  the  outlook  for  further  progress  in  serum  therapy  is  by  no  means 
hopeless  or  discouraging.  The  majority  of  the  difficulties  are  of  a 
character  to  suggest  that  they  are  capable  of  solution.  It  is  for 
this  reason  that  among  the  various  fields  of  medical  research,  the 
greatest  amount  of  activity  is  found  in  the  study  of  infection  and 
immunity.  We  must  look  mainly  to  the  results  of  this  study  and 
research  for  further  advances  in  specific  therapy. 

VACCINE  THERAPY.— This  consists  in  the  inoculation  of  the 
patient  with  a  bacterial  preparation  with  a  view  to  stimulating  the 
patient's  tissues  to  the  production  of  immune  bodies,  or  to  an  immune 
reaction. 

Immunological  studies  have  demonstrated  that  when  bacteria  are 
killed  by  heat,  the  substances  contained  in  the  bacterial  cells  which 
excite  the  formation  of  immune  bodies  in  the  patient,  are  not  destroyed. 
In  some  instances  the  injurious  endotoxin  is  not  the  same  as  the  anti- 
gens, or  substances  which  excite  antibody  formation.  It  is  mainly 
the  multiphcation  of  bacteria  in  the  body  which  causes  harm,  and  this 
is  prevented  by  the  method  of  preparation.  The  majority  of  vaccines 
consist  of  suspensions  of  dead  bacteria  in  normal  salt  solution,  the 
dose  being  measured  by  the  number  of  dead  bacteria  given.  In 
using  a  vaccine,  the  number  of  dead  bacteria  in  a  certain  quantity 
of  the  solution  must  be  known,  in  order  to  regulate  the  dose.  These 
vaccines  are  injected  subcutaneously. 

The  tuberculosis  vaccine  known  as  tubercuhn  is  an  extract  of  the 
tubercle  bacillus,  and  the  dose  is  measured  in  milhgrams.  The 
vaccine  used  against  small-pox  is  the  living  unknown  virus  of  cow- 
pox,  and  is  inoculated  into  an  abrasion  of  the  skin. 

The  chief  value  of  vaccine  therapy  is  prophylactic  rather  than 
curative.  The  efficacy  of  the  inoculation  of  bacterial  products  in 
producing  an  active  immunity  against  certain  diseases,  has  been 
estabhshed  beyond  the  possibiUty  of  a  doubt.  Except  in  the  case 
of  vaccination  against  small-pox,  prophylactic  vaccination  has  at 
present  a  very  small  place  in  pediatrics.     It  is  only  under  exceptional 


152  Disease  in  Easly  Life 

circumstances  of  epidemic  and  exposure  that  prophylactic  inoculation 
is  indicated  in  childhood. 

The  chief  use  of  vaccine  therapy  in  early  hfe  is  as  a  curative  meas- 
ure. Vaccine  therapy  has  been  tried  in  almost  every  known  form 
of  bacterial  infection.  In  general,  the  results  have  been  disappoint- 
ing. In  those  general  infections,  in  which  there  is  a  profound  dis- 
turbance of  the  physiology  of  the  entire  body,  such  as  pneumonia, 
typhoid  fever,  streptococcus  and  staphylococcus  septicaemia,  ulcera- 
tive endocarditis,  and  the  various  forms  of  meningitis,  the  clinical 
evidence  of  good  results  is  not  sufficient  to  justify  the  routine  use  of 
vaccine  therapy.  There  is  evidence  of  a  good  effect  in  some  indi- 
vidual cases,  but  it  must  be  remembered  that  in  these  diseases  the 
body  is  already  inoculated  and  overtaxed  with  toxic  substances,  and 
it  is  difficult  to  see  how  good  may  be  expected  from  adding  to  the 
burden  by  artificial  inoculation. 

In  certain  strictly  locahzed  infections,  on  the  other  hand,  there 
is  abundant  clinical  evidence  that  the  infectious  process  can  often 
be  favorably  influenced  by  bacterial  inoculations.  The  most  con- 
spicuous examples  are  the  various  localized  staphylococcus  infections, 
of  which  furunculosis  is  t^^pical.  But  furunculosis  represents  really 
a  series  of  infections,  rather  than  a  single  one,  and  the  effect  of  vaccine 
therapy  is  probably  chiefly  as  a  prophylactic  against  recurrent  in- 
fection. The  more  nearly  a  localized  infection  approaches  a  type 
resembling  furunculosis,  the  more  promising  is  the  outlook  for  vaccine 
therapy.  In  other  infections,  not  so  strictly  localized,  but  inter- 
mediate in  character  between  the  widespread  and  Hmited  tjqpes,  such 
as  pyelitis,  gonococcus  infection,  certain  forms  of  arthritis,  and  so 
forth,  vaccine  therapy  must  be  considered  as  a  possibihty,  of  which 
the  value  is  not  yet  either  established  or  disproved. 

In  the  selection  of  the  vaccine,  the  physician  must  choose  between 
the  employment  of  an  autogenous  vaccine  or  a  stock  vaccine.  An 
autogenous  vaccine  is  one  prepared  from  a  culture  taken  from  the 
patient  and  contains  the  particular  strain  or  t}pe  of  infecting  organ- 
ism that  is  producing  the  disease.  The  researches  of  recent  years 
have  sho-vvTi  that  one  of  the  chief  elements  leading  to  chronicity  and 
resistance  in  an  infectious  process,  is  a  change  in  the  infecting  organ- 
ism by  which  it  becomes  less  susceptible  to  the  attack  of  the  immune 
bodies  of  the  host.  Artificial  active  immunization,  if  it  is  to  be 
effective,  must  take  cognizance  of  such  elements  as  bacterial  re- 
sistance and  "organ  specificity,"  and  consequently  a  vaccine  should 
be  derived  from  an  organism  possessing  the  properties  of  those  con- 
cerned in  the  infectious  process — an  autogenous  vaccine.  The  tech- 
nique of  the  preparation  of  autogenous  vaccines  varies  somewhat 
with  the  type  of  organism  concerned,  and  for  the  details  the  reader 
is  referred  to  standard  works  on  bacteriology. 


Hygienic  Treatment  153 

Stock  vaccines  are  prepared  from  stock  cultures.  The  advantage 
attending  their  use  is  only  that  they  are  more  easily  obtainable. 
There  is  evidence  that  in  some  types  of  infection  stock  preparations 
are  effective.  We  cannot,  however,  be  sure  of  the  type  of  infection 
without  a  culture,  and  if  a  culture  is  obtainable,  the  preparation  of 
an  autogenous  vaccine  should  be  possible.  Even  if  we  grant  that  a 
correct  bacteriological  diagnosis  can  be  made  from  clinical  observa- 
tion, stock  vaccines  have  the  further  disadvantage  that  they  may  not 
meet  the  final  requirements  of  the  particular  strain  of  organism  in  the 
individual  case.  This  disadvantage  may  be  partly  overcome  by  uniting 
bacteria  from  different  strains  of  the  same  species  in  a  polyvalent 
vaccine.  The  usual  reason  however  for  the  employment  of  a  stock 
vaccine  is  that  the  physician  is  not  master  of  the  technique  of  the 
preparation  of  an  autogenous  vaccine.  While  their  use  under  certain 
circumstances  may  be  justifiable,  it  encourages  loose  thinking  and  neg- 
lect of  the  fundamental  principles  on  which  vaccine  therapy  is  based. 

The  use  of  ''mixed  vaccines,"  or  of  non-specific  mixtures  of  the 
products  of  bacterial  growth,  cannot  be  too  strongly  condemned. 
Such  "shot-gun"  empiricism  in  matters  so  important  as  infection 
and  its  treatment  is  not  only  wholly  unscientific,  but  stands  an  excel- 
lent chance  of  being  actually  extremely  dangerous. 

The  indication  for  vaccine  therapy  and  its  method  of  employment 
will  be  considered  under  the  various  diseases  in  which  it  holds-  a  place 
as  a  prophylactic  or  therapeutic  measure. 

SPECIFIC  MEDICINAL  TREATMENT.— Failure  of  drugs  as 
a  specific  weapon  against  infectious  processes  applies  to  the  bacterial 
diseases  only.  In  infections  produced  by  animal  parasites  such  as 
protozoa  and  others,  there  is  evidence  that  drugs  may  have  a  specific 
value  against  the  pathogenic  invader.  In  pediatrics  there  are  two 
diseases  of  this  class,  malaria  and  syphilis.  The  use  of  quinine  in 
malaria,  and  of  mercury,  salvarsan,  or  iodide  of  potassium  in  syphilis, 
may  be  considered  as  specific  treatment. 

HYGIENIC  TREATMENT 

In  those  diseased  conditions  which  are  directly  due  to  faulty 
hygiene,  hygienic  treatment  may  be  considered  as  specific.  It  holds 
also  a  very  important  place  in  all  the  diseased  conditions  of  early 
life.  The  resistance  of  the  organism  against  adverse  influences  of 
all  kinds,  whether  they  be  infections,  or  whether  they  be  due  to  con- 
stitutional peculiarities  or  external  injuries,  is  largely  dependent 
upon  the  normal  development  and  general  health  of  the  child.  Proper 
hygiene  is  essential  to  the  proper  development  of  a  constitution  which 
is  able  to  resist  disease.  For  this  reason  hygienic  measures  have 
their  place  in  practically  all  diseases. 


154  Disease  in  Early  Liee 

The  details  of  hygienic  treatment  have  been  described  at  length 
in  the  first  division  of  this  book  under  the  heading  of  "The  Hygiene 
and  Care  of  Normal  Children."  The  physician  should  always  devote 
the  greatest  pains  to  discovering  whether  there  are  any  faults  in  the 
hygiene  and  environment  of  his  youthful  patient,  and  should  correct 
such  faults.  It  is  always  the  first  essential  to  place  the  patient  in 
proper  hygienic  surroundings.  The  particular  hygienic  measures 
which  are  demanded  by  certain  special  diseased  conditions  will  be 
described  under  the  several  divisions. 

DIETETIC  TREATMENT 

A  large  group  of  the  diseased  conditions  encountered  in  infancy 
and  early  childhood  are  due  to  the  relatively  low  resistance  of  the 
functions  of  digestion  and  metabolism  against  adverse  influences. 
In  this  group,  treatment  is  mainly  dietetic,  and  here,  dietetic  treat- 
ment may  be  considered  specific.  The  susceptibility  of  the  gastro-in- 
testinal  system  in  early  life  must  be  taken  into  consideration  also  in 
all  the  diseased  conditions  of  childhood,  and  consequently  the  proper 
arrangement  of  the  diet  plays  a  very  important  part  in  the  therapeu- 
tics of  early  life.  The  details  will  be  considered  at  length  in  this 
book  in  the  divisions  on  Feeding  and  on  the  Gastro-Intestinal  Dis- 
eases. 

SYMPTOMATIC  TREATMENT 

This  is  directed  at  the  various  functional  disturbances  which  appear 
as  manifestations  of  disease.  It  must  be  remembered,  however,  that 
in  children  the  e\'idences  of  disturbed  function  are  not  always  an 
indication  for  treatment.  Symptomatic  treatment  is  indicated 
under  two  conditions:  (i)  When  the  manifestations  of  disturbed  func- 
tion are  uncomfortable  or  painful,  and  (2)  when  they  are  harmful 
or  dangerous.  The  mere  fact  that  a  child  has  fever  or  a  rapid  pulse, 
does  not  mean  that  these  symptoms  are  necessarily  to  be  treated. 
The  indications  for  symptomatic  treatment  vary  with  the  disease 
and  with  the  gravity  of  the  s^nnptoms. 

The  remedial  measures  employed  in  symptomatic  treatment  can 
be  roughly  classified  according  to  the  particular  physiologic  system 
whose  function  is  disturbed.  Measures  directed  at  the  reduction  of 
bodily  temperature  are  called  antipyretic.  Measures  directed  at 
remedying  disturbed  function  of  the  circulatory  system  include 
stimulants  and  counterirritants.  Measures  which  aid  the  renal  func- 
tion are  called  diuretic.  The  measures  directed  at  the  relief  of 
pain  are  called  analgesic,  and  include  the  opiates.  Disturbance  of 
the  function  of  the  nervous  system  is  controlled  by  the  sedatives. 
Measures  designed  to  aid  the  general  metabolism  may  be  classified 
as  tonics. 


General  Therapeutic  Measures  155 

The  measures  employed  in  the  symptomatic  treatment  of  diseases 
may  be  classified  in  another  way,  according  to  whether  they  do  or 
do  not  involve  the  use  of  drugs.  They  will  be  described  under  this 
classification. 

THERAPEUTIC  MEASURES  OTHER  THAN  DRUGS 

These  play  a  very  important  part  in  the  therapeutics  of  infancy 
and  childhood. 

HEAT  AND  COLD.  The  Ice  Bag.— The  application  of  cold  is, 
useful  in  many  conditions.  AppHed  to  the  head,  it  is  useful  both 
for  the  reduction  of  temperature  and  for  the  relief  of  pain.  In  other. 
parts  of  the  body  it  is  often  indicated  as  an  analgesic  measure,  and 
when  applied  to  the  precordia  may  have  some  favorable  influence 
on  cardiac  function.  It  is  useful  in  many  forms  of  local  inflammation. 
In  very  young  and  delicate  children  it  should  be  used  with  caution. 
Cold  is  usually  applied  by  means  of  an  ice  bag.  On  the  head,  an 
ice  cap  made  like  a  helmet,  may  be  used.  On  the  eyes,  cold  com- 
presses are  employed,  which  are  frequently  changed. 

The  Hot  Water  Bag. — The  appHcation  of  the  hot  water  bag  is 
useful  in  symptomatic  treatment  of  pain,  particularly  when  referred 
to  the  abdominal  cavity. 

Poultices. — These  are  useful  for  the  treatment  of  pain,  and  in 
certain  local  infections  in  hastening  the  formation  of  definite  suppura-. 
tion.  The  flaxseed  poultice,  or  a  poultice  made  from  hot  antiseptic 
solutions  may  be  used. 

The  Hot  Pack. — The  naked  body  of  the  child  is  covered  with 
towels  wrung  from  water  at  a  temperature  of  ioo°  to  io8°  F.,  and  is 
then  rolled  in  a  thick  blanket.  The  hot  application  may  be  changed 
every  half  hour  until  the  required  amount  of  free  perspiration  is  pro- 
duced.    The  chief  use  of  this  procedure  is  in  nephritis. 

The  Hot  Air  Bath. — After  removal  of  the  clothing,  the  patient 
is  laid  upon  the  bed  with  the  bedclothes  raised  about  a  foot  above 
the  body  by  means  of  some  sort  of  wicker  support.  The  bedclothing 
is  fastened  tightly  about  the  neck  of  the  patient.  Hot  air  from  a 
lamp  of  some  kind  is  conducted  through  a  tin  pipe  beneath  the  bed- 
clothes. The  hot  air  bath  may  be  continued  from  fifteen  to  thirty 
minutes  at  a  time.  Free  perspiration  will  usually  be  produced  in 
fifteen  or  twenty  minutes.  The  chief  use  of  this  procedure  is  in 
nephritis. 

HYDROTHERAPY.  The  Hot  Bath.— The  patient  is  put  into 
water  at  a  temperature  of  ioo°  F.,  and  the  temperature  of  the  water 
is  gradually  raised  by  the  addition  of  hot  water  to  from  103°  to  106°  F. 
The  body  of  the  patient  should  be  thoroughly  rubbed  ijvhile  the  patient 


156  Disease  in  Early  Life 

is  in  the  bath.  A  thermometer  in  the  bath  must  be  carefully  watched. 
The  chief  use  of  the  hot  bath  is  in  promoting  reaction  in  cases  of 
shock  or  collapse. 

The  Mustard  Bath. — Four  tablespoonfuls  of  powdered  mustard 
are  mixed  with  one  gallon  of  tepid  water,  and  enough  water  is  added 
to  this  to  make  five  gallons,  at  a  temperature  of  ioo°  F.  The  mus- 
tard bath  is  useful  in  cases  of  shock,  collapse,  or  sudden  heart  failure, 
especially  in  infancy.  The  duration  of  the  bath  should  be  not  more 
than  ten  minutes,  but  it  may  be  repeated  in  an  hour  if  necessary. 

The  Tepid  Bath  is  given  at  a  temperature  of  95  to  100°  F.  The 
patient  should  be  left  in  the  bath  about  ten  minutes.  This  procedure 
is  mainly  useful  in  conditions  of  irritability  of  the  nervous  system, 
and  to  promote  sleep.     It  is  often  more  effective  than  drugs. 

The  Cold  Sponge.- — For  this  purpose  equal  parts  of  alcohol  and 
water  are  used  at  a  temperature  from  So°  to  85°  F.  The  naked  child 
is  laid  upon  a  blanket,  and  the  body  should  be  sponged  for  from  ten 
to  twenty  minutes,  with  occasional  rubbing  of  the  skin.  After  the 
sponging,  the  child  is  wrapped  in  a  blanket  -without  further  dressing. 

This  procedure  is  occasionally  indicated  in  reducing  high  tempera- 
ture. Its  chief  value,  however,  is  in  rehe\dng  symptoms  of  irritation 
of  the  nervous  system  in  certain  diseases.  It  is  less  effective,  but 
also  less  depressing  than  the  cold  pack. 

The  Cold  Pack.— The  naked  child  is  laid  upon  a  blanket,  and 
the  entire  trunk  is  enveloped  in  a  sheet  \\Tung  from  water  at  a  tem- 
perature of  100°  F.  Ice  is  now  rubbed  upon  the  outer  surface  of  the 
sheet,  first  in  front,  then  behind,  so  that  the  entire  trunk  is  included. 
The  child  is  then  left  in  the  pack  for  a  varying  time,  according  to  the 
circumstances  of  the  case,  during  which  the  rubbing  with  ice  is  once 
repeated.  The  child  is  then  wrapped  in  a  blanket  without  removing 
the  wet  sheet,  and  left  in  this  about  an  hour,  when  it  may  be  dried  and 
■v\Tapped  in  another  blanket. 

This  is  the  most  eft'ective  means  of  reducing  the  temperature  in 
infancy  and  childhood.  It  has  the  advantage  of  avoiding  all  shock 
and  fright.  It  may  be  necessary  to  apply  heat  to  the  lower  extrem- 
ities while  the  child  is  in  the  pack.  . 

The  Cold  Bath. — This  is  sometimes  employed  as  an  antipyretic 
measure,  but  much  less  often  in  children  than  in  adults.  The  cold 
pack  is  to  be  preferred  in  most  cases.  The  child  is  placed  in  a  bath 
at  a  temperature  of  100°  F.  The  temperature  of  the  bath  is  then 
gradually  lowered  by  the  addition  of  cold  water  to  from  80°  to  85°  F. 
The  body  of  the  child  should  be  vigorously  rubbed  while  it  is  in  the 
bath,  and  water  should  be  applied  to  the  head.  The  bath  should 
be  continued  for  from  five  to  ten  minutes,  after  which  the  child  is 
removed,  dried  quickly  and  rolled  in  a  blanket. 


General  Therapeutic  Measures  157 

COUNTERIRRITATION.  Mustard  Paste.— This  is  made  as 
follows:  Take  one  part  powdered  mustard  and  six  parts  flour,  mix 
with  warm  water,  and  spread  between  two  layers  of  muslin.  This  is 
applied  to  the  region  where  counterirritation  is  desired,  and  held  in 
place  by  a  swathe  or  simple  bandage.  The  effect  on  the  skin  should 
be  carefully  watched,  and  the  paste  should  be  removed  as  soon  as  a 
decided  redness  of  the  skin  has  been  produced.  In  most  cases,  this 
will  not  take  much  longer  than  five  minutes.  The  paste  may  be 
made  somewhat  stronger  for  older  children  than  for  infants.  The 
application  of  a  mustard  paste  may  be  repeated  as  often  as  every 
three  hours  if  desired. 

This  is  the  most  efficient  means  of  producing  a  rapid  counter- 
irritation  over  a  large  surface.  It  is  sometimes  useful  in  pulmonary 
diseases. 

The  Mustard  Pack. — The  naked  child  is  laid  upon  a  blanket 
and  its  body  is  wrapped  in  a  large  towel  or  small  sheet,  which  has  been 
saturated  with  mustard  water  of  a  strength  of  one  tablespoonful  of 
mustard  to  one  gallon  of  warm  water.  The  patient  is  then  rolled 
in  a  blanket.  The  pack  is  continued  until  a  notable  redness  of  the 
entire  body  has  been  produced. 

The  mustard  pack  is  useful  in  the  same  conditions  as  the  mustard 
bath,  namely,  sudden  collapse,  great  prostration,  and  internal  con- 
gestion. It  is  less  efficient  than  the  mustard  bath,  but  has  the  advan- 
tage of  being  less  disturbing  to  the  patient. 

The  Turpentine  Stupe. — Wring  a  piece  of  flannel  out  of  water 
as  hot  as  can  be  borne  by  the  hand,  sprinkle  upon  it  ten  or  twelve 
drops  of  spirits  of  turpentine,  apply  directly  to  the  aft'ected  part, 
and  cover  with  dry  flannel.  Care  must  be  taken  in  using  turpentine 
stupes  in  infants,  as  they  easily  produce  blistering  of  the  skin.  The 
chief  use  of  the  turpentine  stupe  is  in  abdominal  pain,  or  inflamma- 
tion, or  in  abdominal  distention. 

Bleeding. — Venesection  is  almost  never  indicated  in  the  diseases 
of  infancy  and  childhood.  Local  bloodletting  by  means  of  leeches 
are  sometimes  useful  in  certain  conditions  such  as  mastoid  disease, 
or  thoracic  disease  with  marked  dyspnoea  and  cyanosis.  Dry  cup- 
ping may  also  be  employed  in  some  similar  conditions.  Wet  cupping 
is  never  indicated  in  early  life. 

IRRIGATIONS  AND  SPRAYS.  Irrigation  of  the  Colon.— 
This  is  one  of  the  most  important  of  all  the  therapeutic  procedures 
used  in  infancy  and  early  childhood.  Irrigation  of  the  colon  must 
not  be  confused  with  enemata.  The  object  is  to  flush  the  entire 
large  intestine  with  fluid,  injected  as  high  up  as  possible. 

The  apparatus  required  is  a  fountain  syringe  holding  at  least  two 
quarts,  four  or  five  feet  of  rubber  tubing,  and  a  soft  rubber  catheter 


158 


Disease  in  Early  Life 


of  a  size  about  number  26  French  scale.  The  catheter  is  connected 
with  the  rubber  tubing  coming  frorn  the  syringe  by'  means  of  a  bit 
of  glass  tubing.  In  place  of  the  fountain  syringe,  a  fuimel  and 
pitcher  may  be  employed.  Double  current  tubes,  or  two  catheters, 
one  for  outflow,  the  other  for  inflow,  are  unnecessary.  The  syringe 
is  hung  about  two  feet  above  the  level  of  the  child,  and  is  filled  with 
the  irrigating  fluid,  which  in  routine  cases  should  be  normal  salt 
solution. 

Fig.  43 


Irrigation  of  the  colon 


The  child  is  placed  upon  its  back  with  the  thighs  flexed,  and  the 
buttocks  brought  to  the  edge  of  the  bed  or  table.  A  Kelly  pad  or 
rubber  sheet  should  be  arranged  to  form  a  trough  leading  into  a  tub 
or  large  basin.  The  catheter  is  oiled,  and  the  water  is  turned  on  and 
allowed  to  flow  until  the  cold  water  in  the  tube  has  escaped.  The  end 
of  the  catheter  is  then  introduced  through  the  anus  with  the  water 
flowing,  and  is  gradually  pushed  upward  as  far  as  possible,  usually 
for  a  distance  of  twelve  or  fourteen  inches.  The  pushing  of  the 
catheter  is  rendered  easy  by  the  fact  that  the  running  water  distends 
the  intestine  ahead  of  the  tube.  If  on  account  of  the  peristalsis 
excited,  the  catheter  turns  on  itself  and  comes  back  through  the  anus, 
it  must  be  reintroduced  and  pushed  up  again.  There  is  no  danger 
of  over-distention  of  the  intestine,  as  active  peristalsis  is  always  ex- 


o 


General  Therapeutic  Measures  159 

cited  and  the  water  comes  back  through  the  anus  around  the  catheter. 
Usually  a  pint  or  more  will  enter  before  the  fluid  begins  to  return. 
The  irrigation  should  be  continued  until  the  water  comes  back  en- 
tirely clear,  but  at  least  two  quarts  should  always  be  given.  During 
the  irrigation  gentle  massage  of  the  abdomen  will  facilitate  the  reach- 
ing of  the  upper  part  of  the  colon.  After  the  irrigation,  the  rubber 
tube  is  disconnected  and  the  remaining  water  is  allowed  to  escape 
through  the  catheter.     Some  is  usually  retained  and  passed  later. 

The  temperature  of  the  water  used  in  irrigation  for  ordinary  pur- 
poses should  be  from  95°  to  100°  F.  It  may  be  varied  according  to 
special  indications,  as  when  there  is  high  fever,  or  when  there  is  pain 
and  tenesmus;  in  these  cases  colder  irrigating  fluid  is  of  advantage. 
In  some  cases,  instead  of  normal  saline  solution,  plain  water  or  some 
medicated  fluid  may  be  used. 

Irrigation  of  the  colon  should  never  be  used  more  than  twice  in 
twenty-four  hours.  It  is  wise  for  the  physician  to  make  sure  that 
the  nurse  thoroughly  understands  the  technique,  as  otherwise  only 
a  rectal  injection  will  be  given.  It  is  often  a  good  plan  for  the  physi- 
cian to  give  the  first  irrigation  himself.  The  essential  points  are  the 
high  introduction  of  the  tube,  and  the  use  of  a  large  quantity  of  water. 

Gastric  Lavage. — Stomach  washing  is  frequently  indicated  in 
the  diseases  of  infancy  and  early  childhood,  and  is  one  of  the  most 
valuable  therapeutic  procedures  which  we  have.  It  is  not,  as  is 
often  supposed,  attended  by  shock  or  prostration  in  infants,  and  it 
is  entirely  free  from  danger. 

The  apparatus  for  stomach  washing  consists  of  a  soft  rubber  cathe- 
ter, a  glass  funnel  attached  to  a  rubber  tube,  and  a  glass  "window"  con- 
nection between  the  other  end  of  the  rubber  tube  and  the  catheter. 
The  child  is  wrapped  up  with  the  arms  confined  and  is  held  in  a 
sitting  position,  with  a  large  basin  at  the  nurse's  feet.  The  physi- 
cian depresses  the  tongue  with  the  forefinger  of  the  left  hand,  and 
with  the  right  hand  passes  the  catheter  rapidly  backward  into  the 
pharynx  and  down  into  the  esophagus.  The  passage  of  the  catheter 
past  the  pharynx  will  cause  gagging,  and  for  this  reason  this  part  of 
the  introduction  should  be  made  rapidly.  The  catheter  is  now  pushed 
downward  more  slowly.  A  second  gagging  mil  usually  betray  the 
moment  when  the  catheter  passes  the  cardiac  orifice  and  enters 
the  stomach. 

The  catheter  is  now  passed  a  little  further  downward.  The  en- 
trance into  the  stomach  is  often  shown  by  the  escape  of  curdled 
milk  from  the  funnel.  The  distance  from  the  teeth  to  the  stomach 
varies  with  the  size  of  the  child.  It  is  approximately  about  ten  in- 
ches, but  the  physician  can  usually  recognize  the  entrance  into  the 
stomach  by  the  distinct  reflex  at  the  cardiac  orifice.     When  the 


160 


Disease  in  Early  Lite 


catheter  has  entered  the  stomach,  the  funnel  should  be  raised  as  high 
as  possible,  to  facihtate  the  escape  of  any  gas  which  may  be  present, 
and  should  then  be  lowered  in  order  to  siphon  out  any  fluid  con- 
tents. The  funnel  is  then  raised  and  warm  water  at  a  temperature 
of  about  ioo°  F.  is  poured  into  it  from  a  pitcher.  The  amount  of 
water  varies  with  the  age  of  the  child,  and  should  be  approximately 
equal  to  the  quantity  of  milk  given  at  a  feeding  at  that  age.  The 
funnel  is  then  lowered  and  the  water  is  siphoned  out.  This  pro- 
cedure is  repeated  a  number  of  times  until  the  fluid  comes  back  clear. 
A  number  of  repeated  washings  are  often  required  to  break  up  the 
large  curds  which  sometimes  interfere  with  the  flow  of  fluid. 

Stomach  washing  is  practically  never  employed  in  children  over 
three  years  old,  and  is  most  commonly  indicated  in  the  first  two 
years  of  Hfe.  Indications  for  this  procedure  will  be  given  under  the 
several  diseases  in  which  it  is  used. 


Fig.  47 


Irrigation  of  the  ear 


Syeinging  the  Ears.— This  is  best  performed  with  a  syringe  made 
entirely  of  soft  rubber.  The  child  should  be  lying  on  its  back  in 
the  position  shown  in  the  illustration.  This  is  one  of  the  most  fre- 
quent procedures  in  the  therapeutics  of  early  hfe,  owing  to  the  very 
common  occurrence  of  middle  ear  disease. 


General  Therapeutic  Measures  161 

Nasal  Irrigation. — This  may  be  given  by  means  of  a  fountain 
syringe,  or  with  any  form  of  hand  syringe  which  has  a  soft  rubber 
tip  and  with  which  the  pressure  can  be  easily  regulated.  The  foun- 
tain syringe  should  not  be  higher  than  two  feet  above  the  child. 
The  patient  lies  on  its  side  with  its  mouth  open.  The  irrigation  is 
given  through  the  upper  nostril,  and  then  the  child  is  turned  on  the 
other  side  for  irrigation  through  the  other  nostril.  The  fluid  should 
return  either  through  the  lower  nostril  or  through  the  mouth.  Care 
must  be  taken  in  using  the  hand  syringe  not  to  employ  too  much 
pressure,  as  the  fluid  may  be  forced  into  the  eustachian  tubes. 

Fig.  48 


Irrigation  of  the  nose 

Spraying  the  Nose  and  Throat. — This  procedure  is  best  performed 
with  some  form  of  atomizer.  Either  aqueous  or  oily  solutions  are  used, 
the  character  of  the  solution  being  determined  by  that  of  the  disease. 

Gargles. — Gargling  the  throat  is  impossible  with  infants  and  is 
only  used  in  older  children.  The  character  of  the  gargle  varies  with 
that  of  the  condition  in  which  it  is  indicated. 

Syringing  the  Mouth  and  Throat. — This  is  sometimes  indicated 
in  children  too  young  to  gargle.     The  child  should  either  be  lying 
on  its  side,  or  held  in  a  sitting  posture  with  the  head  inclined  forward. 
Any  form  of  syringe  may  be  used  in  this  procedure. 
11 


162  Disease  in  Early  Life 

INHALATIONS. — These  are  very  useful  in  various  affections  of 
the  respiratory  tract.  They  are  given  in  the  form  of  vapor,  either 
plain  steam  being  employed,  or  vapor  from  boiling  water  to  which 
some  medicinal  agent  has  been  added.  In  the  mildest  cases,  a  bowl 
of  boiling  water  may  be  surrounded  with  a  newspaper  folded  in  such 
a  way  as  to  concentrate  the  vapor,  and  the  child  is  held  over  the  bowl 
and  allowed  to  breathe  the  steam.  To  be  thoroughly  effective,  how- 
ever, the  patient  should  be  under  a  tent.  Such  a  tent  can  be  impro- 
vised in  the  crib  in  various  ways  by  means  of  a  sheet.  A  rubber 
sheet  is  often  better  than  an  ordinary  cotton  one.  To  generate  the 
steam,  some  sort  of  croup  kettle  or  vaporizer  may  be  employed,  and 
some  efficient  and  safe  means  must  be  devised  to  conduct  the  steam 
from  the  croup  kettle  or  vaporizer  to  the  tent.  Many  of  the  croup 
kettles  on  the  market  are  dangerous,  but  there  are  some  good  ones. 
There  are  various  forms  of  apparatus  for  giving  medicated  inhala- 
tions. The  Cresolene  lamp  is  in  common  use,  but  steam  inhala- 
tions with  tent  and  croup  kettle  are  preferable. 

ENEMATA. — Enemata  are  used  for  four  purposes,  (i)  as  a  means 
of  emptying  or  cleansing  the  bowel,  (2)  as  a  means  of  introducing 
nutriment,  (3)  as  a  means  of  introducing  medication,  (4)  as  a  means 
of  introducing  fluid  or  of  stimulation. 

Laxative  or  Cleansing  Enemata. — For  the  purpose  of  simply 
emptying  the  bowel  or  of  cleansing  the  rectum,  the  ordinary  soap- 
suds enema  is  best.  In  marked  constipation  when  the  fecal  mass 
is  hard  and  dry,  enemata  of  olive  oil  are  used — about  one  ounce, — 
and  they  may  often  be  advantageously  followed  by  a  soapsuds  enema. 

If  an  immediate  and  certain  emptying  of  the  bowels  is  desired,  a 
teaspoonful  of  glycerin  in  one  ounce  of  water  should  be  injected  for 
an  infant,  a  larger  quantity  being  used  for  older  children. 

Nutrient  Eneiviata. — Peptonized  milk  was  formerly  recom- 
mended, but  I  am  convinced  that  the  most  efficient  nutrient  enemata 
should  consist  of  a  solution  of  dextrose  (glucose).  A  six  per  cent, 
solution  should  be  employed,  and  the  quantity  given  at  each  injec- 
tion should  vary  with  the  age  of  the  child.  Young  infants  will  not 
retain  more  than  one  or  two  ounces,  older  infants  not  more  than  two 
to  four  ounces,  older  children  four  to  six  ounces.  The  interval  be- 
tween the  injections  should  usually  be  four  hours. 

Medicated  Enemata. — The  giving  of  drugs  by  rectum  is  often 
indicated  in  infancy  and  childhood,  either  on  account  of  vomiting 
or  on  account  of  the  unpleasant  taste.  The  medicine  may  be  given 
in  water  or  in  gruel.  The  quantity  of  diluent  used  should  be  the 
same  as  for  nutrient  enemata.  With  both  nutrient  and  medicated 
enemata  it  is  useful  in  infancy  to  press  the  buttocks  together  for 
half  an  hour  after  the  injection,  to  prevent  expulsion. 


1 


General  Therapeutic  Measures  163 

Stimulant  Enemata. — These  are  employed  mainly  for  the  pur- 
pose of  introducing  fluid  into  the  circulation.  Stimulating  drugs 
are  best  given  hypodermically  or  intravenously.  The  normal  saUne 
solution  may  often  best  be  introduced  by  rectum.  Enemata  of 
normal  sahne  solution  may  be  given  at  intervals  in  the  same  quan- 
tities as  are  used  for  nutrient  enemata,  the  object  being  to  give 
as  much  fluid  as  possible  without  producing  intolerance  of  the  rectum. 

Another  procedure  is  to  give  the  normal  salt  solution  by  means 
of  seepage.  A  fountain  syringe  connected  by  means  of  a  rubber 
tube  with  a  soft  rubber  catheter  is  used.  The  syringe  is  hung 
at  an  appropriate  height  above  the  bed,  and  is  kept  warm  by  being 
surrounded  with  some  form  of  thick  covering.  The  solution  should 
be  changed  when  it  becomes  cold.  An  attachment  is  placed  upon 
the  rubber  tube,  by  means  of  which  compression  of  the  tube  can 
be  varied,  and  in  this  way  the  rate  of  flow  of  the  solution  can  be 
regulated.  It  may  be  started  at  ten  drops  per  minute,  but  if  the 
patient  begins  to  pass  fluid  from  the  rectum,  the  rate  of  flow  should 
be  decreased,  the  object  being  to  give  as  much  fluid  as  can  be  retained 
and  absorbed.  In  this  way  fluid  can  be  given  continuously  without 
producing  intolerance. 

GAVAGE  AND  NASAL  FEEDING.-Tn  a  great  number  of  con- 
ditions in  early  life  patients  are  unable  or  unwilUng  to  swallow 
sufficient  nutriment.  Gavage  is  a  very  important  procedure  in 
pediatrics.  The  same  apparatus  is  employed  as  in  stomach  washing — • 
soft  rubber  catheter,  connecting  tube,  and  funnel.  The  technique  is 
the  same  as  that  described  for  stomach  washing,  except  that  it  is 
preferable  to  have  the  child  lying  upon  its  back  instead  of  in  a  sitting 
posture.  The  catheter  is  introduced  into  the  stomach  through  the 
mouth,  and  after  the  funnel  has  been  raised  to  allow  the  gas  to 
escape,  the  food  is  poured  into  the  funnel.  Before  withdrawing 
the  tube,  it  should  be  tightly  pinched  in  order  to  prevent  any  fluid 
from  trickling  into  the  pharynx,  and  the  tube  should  be  withdrawn 
quickly. 

The  introduction  of  the  catheter  through  the  nose  is  possible, 
and  was  formerly  recommended  for  gavage.  The  introduction  of 
the  catheter  through  the  mouth  is  preferable,  but  there  are  certain 
cases  in  which  nasal  feeding  must  be  used.  When  gavage  is  neces- 
sary in  children  over  two  years  old,  the  tube  cannot  be  passed  through 
the  mouth  without  the  use  of  a  gag,  and  then  only  after  much  strug- 
gHng.  There  are  also  certain  cases  in  which,  on  account  of  opera- 
tions about  the  throat  or  lesions  in  the  throat,  nasal  feeding  is  better. 

MASSAGE.— This  is  useful  in  older  children  in  the  same  condi- 
tions as  those  for  which  it  is  employed  in  adults.  It  is  best  whenever 
possible  to  have  a  trained  masseur.     In  infancy  true  massage  is  not 


164  Disease  m  Early  Life 

often  indicated.  Massage  of  the  abdomen  is  occasionally  used  in 
constipation.  Friction  of  the  skin  either  with  the  bare  hand  or  wdth 
cocoa  butter  is  sometimes  indicated  in  infants.  Cod  hver  oil  is 
widely  used  for  this  purpose,  but  is  very  disagreeable,  and  has  no 
advantages  over  cocoa  butter. 

HYPODERMOCLYSIS.— The  introduction  of  fluid  under  the 
skin  is  often  a  very  valuable  therapeutic  measure  in  infancy  and 
childhood.  The  object  is  to  compensate  for  loss  of  fluid,  to  give  addi- 

No.  51 


F 


~wi — 1  \ 


.-«(| 


Xasal  feeding 

tional  fluid,  and  to  stimulate  the  general  circulation.  It  is  an  alter- 
native procedure  to  the  giving  of  normal  salt  solution  by  rectum, 
and  is  a  preferable  method  in  certain  conditions.  In  other  con- 
ditions, the  skin  is  used  in  addition  to  the  rectum,  or  is  substituted 
for  the  rectum  when  the  latter  becomes  intolerant.  Sterile  normal 
salt  solution  at  body  temperature  should  be  employed.  It  is  injected 
by  means  of  an  appropriate  syringe  and  an  ordinary  antitoxin 
needle,  both  needle  and  syringe  being  sterilized.  Injections  may  be 
made  between  the  scapulae,  into  the  skin  of  the  abdomen,  or  in  the 
lateral  thoracic  region.  The  amount  injected  at  one  time  in  an 
infant  should  be  from  one  to  four  ounces,  and  in  an  older  child 
from  four  to  six  ounces. 


General  Therapeutic  Measures  165 

INTRAVENOUS  INJECTIONS.— This  procedure  has  hitherto 
been  very  httle  if  at  all  employed  in  infancy  and  childhood,  princi- 
pally on  account  of  the  difficult  technique  caused  by  the  small  size 
of  the  veins.  I  have  recently  adopted  the  plan  of  employing  the 
longitudinal  sinus  for  purposes  of  intravenous  injection  in  infants  with 
open  fantanelles.  This  greatly  simpUfies  the  technique,  and  I  have 
been  gradually  using  intravenous  injections  more  and  more  in  infancy. 

Drugs — including  the  various  stimulants  from  which  quick  action 
is  desired — salvarsan  in  syphilis,  and  sodium  bicarbonate  in  acidosis, 
may  be  given  in  this  way.     It  is  a  most  efficient  means  of  intro- 

FiG.  52 


Intravenous  injections  in  infancy — tapping  the  cerebral  ventricles 
A.  Point  where  the  needle  is  introduced  in  obtaining  blood  for  examination,  and  for 
intraveneous  injections  and  transfusion 
B.  Point  where  the  needle  is  introduced  in  tapping  the  cerebral  ventricle 

ducing  normal  salt  solution  rapidly  into  the  general  circulation. 
Nutriment  also  may  be  introduced  directly  into  the  blood  in  the  form 
of  dextrose  by  means  of  this  procedure.  I  have  found  intravenous 
dextrose  injections  of  great  value  in  certain  cases  of  extreme  inani- 
tion, atrophy,  and  malnutrition,  and  have  been  able  to  demonstrate 
that  most  if  not  all  of  the  dextrose  thus  introduced  is  actually  utilized 
for  the  purpose  of  energy  production,  only  a  little  if  any  being  excreted 
in  the  urine. 


166 


Disease  ix  Early  Life 


The  technique  is  simple.  If  the  injection  is  of  a  small  bulk  which 
can  be  contained  in  a  small  syringe,  no  more  apparatus  is  required 
than  a  sterile  syringe  and  h\-podermic  needle.  If  the  injection  is  of 
larger  bulk,  as  in  the  case  of  normal  saHne,  sodium  bicarbonate,  or 
dextrose  injections,  a  somewhat  larger  needle  must  be  used,  and  this 
is  connected  with  a  rubber  tube,  which  in  turn  is  connected  \\dth  a 
large  syringe.  A  funnel  may  be  employed  instead  of  a  syringe,  but 
a  syringe  has  the  advantage  that  with  it  the  physician  can  make 
sure  that  the  needle  is  actually  in  the  sinus. 


Fig.  53 


Intravenous  injection  in  infancj' 


Before  beginning  the  injection  the  entire  apparatus  is  sterilized. 
Two  assistants  are  required,  one  to  hold  the  child's  head  hrmly,  the 
other  to  manage  the  syringe.  The  syringe  is  filled  vdih  the  fluid  to 
be  injected,  connected  with  the  tube  and  needle,  and  all  air  is  expelled. 
The  region  of  the  fontanelle  is  sterilized  and  the  physician  enters 
the  needle  in  the  median  hne  at  the  posterior  angle  of  the  fontanelle. 
The  entrance  of  the  needle  into  the  sinus  can  usually  be  recognized 
by  a  sudden  lessening  of  the  resistance.  The  physician  now  holds 
the  needle  steady  while  the  assistant  in  charge  of  the  syringe  slightly 
withdraws  the  piston.     If  the  needle  is  in  the  vein,  blood  will  imme- 


Fig.  49 — Tube  feeding,  first  step  ^ 


m 


Useful  Drugs  167 

diately  appear  at  the  glass  window  of  the  tube.  The  assistant  then 
reverses  the  pressure  and  slowly  injects  the  fluid  into  the  sinus.  •  Dis- 
tention of  the  veins  of  the  scalp  is  a  sign  that  the  fluid  is  being  injected 
too  rapidly.  The  injection  should  consume  from  ten  to  fifteen  min- 
utes, and  the  amount  injected  should  be  one  sixtieth  of  the  infant's 
body  weight.     In  dextrose  injections  a  5  per  cent,  solution  is  used. 

USEFUL  DRUGS  IN  INFANCY  AND  CHILDHOOD 

The  number  of  drugs  used  in  the  treatment  of  disease  in  infancy 
and  childhood  is  comparatively  small.  It  is  far  better  for  the  physi- 
cian to  understand  thoroughly  the  use  of  a  few  drugs  than  to  use 
many  at  random.  It  is  essential  also  that  the  physician  shall  thor- 
oughly understand  the  action  of  ever}^  drug  used,  and  that  he  should 
never  prescribe  a  drug  unless  the  indications  for  its  use  are  clear.  In 
considering  the  indications  for  drug  treatment,  it  is  important  to 
remember  the  idiosyncrasies  of  children  in  general  toward  drugs,  and 
also  to  be  on  the  w^atch  for  individual  idiosyncrasy. 

In  giving  a  drug,  the  physician  should  proportion  the  dose  to  the 
age  of  the  patient,  and  when  a  drug  has  been  given,  he  should  watch 
carefully  its  eft"ect.  If  the  desired  eft'ect  is  produced  without  toxic 
symptoms,  it  is  a  sign  that  the  dose  is  sufficient.  If  toxic  effects 
occur,  the  drug  should  be  omitted  for  a  time,  and  when  it  is  resumed 
smaller  doses  should  be  given.  If  no  effect  is  observed,  increase  the 
dose,  carefully  watching  for  either  a  good  or  a  toxic  effect.  If  no 
effect  is  then  produced,  the  drug  or  particular  preparation  must  be 
changed. 

In  the  following  list,  those  drugs  which  are  most  important  and 
most  frequently  used  in  the  treatment  of  infants  and  children  are 
indicated.  It  is  assumed  that  the  physician  is  familiar  with  the  gen- 
eral description  of  these  drugs  and  with  the  facts  about  their  action, 
elimination,  toxic  effects,  and  contraindications.  The  purpose  of  the 
list  is  mainly  to  point  out  the  particular  purposes  for  which  the 
drugs  are  used  in  early  life,  to  point  out  any  peculiarities  which  attend 
their  administration  to  infants  and  children,  and  to  indicate  the  doses 
appropriate  at  the  dift'erent  ages.  It  is  extremely  difficult  to  classify 
the  drugs  which  are  most  useful  in  Pediatrics.  They  cannot  well  be 
divided  on  a  basis  of  their  importance  on  account  of  the 
great  diversity  of  the  purposes  for  which  they  are  used.  The 
classification  used  in  the  list  is  not  by  any  means  complete.  Many 
of  the  drugs  listed  under  one  heading  have  also  a  pharmacological 
action  which  would  bring  them  under  another  heading.  The  classi- 
fication is  used  mainly  for  convenience,  and  no  efl"ort  is  made  to  list 
them  in  the  order  of  the  frequency  of  their  employment.  The  doses 
given  are  minimum,  those  with  which  it  is  safe  to  begin. 


168  Disease  in  Early  Life 

STIMULANTS  AND  DIURETICS.— This  group  includes  drugs 
whose  principal  action  is  upon  the  circulatory  system  or  upon  renal 
function,  and  their  principal  use  is  in  the  symptomatic  treatment 
of  disturbance  of  these  functions. 

Caffein. — This  is  the  most  generally  useful  circulatory  stimulant 
in  the  diseases  of  early  life.  It  is  used  particularly  in  threatening 
circulatory  failure  of  toxic  origin  such  as  occurs  in  many  of  the  acute 
infectious  diseases.  This  circulatory  failure  is  usually  due  as  much 
to  vasomotor  paralysis  as  to  cardiac  weakness,  and  caffein  acts  both  as 
a  vasomotor  and  cardiac  stimulant.  More  specific  symptomatic 
indications  for  its  use  will  be  given  under  the  various  diseases 
in  which  it  is  employed.  It  is  best  given  in  the  form  of  caffein- 
sodium-benzoate,  or  caffein-sodium-salicylate.  It  is  most  often  used 
hypodermically,  but  may  be  given  by  mouth.  The  hypodermic 
dose  is  as  follows: 


One  to  six  months, 

gr.  i/8 

Six  months  to  two  years, 

gf-  1/4 

Two  to  five  years, 

gr.  1/2 

Over  five  years, 

gr-  I 

Given  every  four  hours,  or  as  indicated. 

Digitalis.— This  is  used  as  a  cardiac  stimulant  in  circulatory 
disturbance  caused  by  disease  of  the  heart  itself.  It  is  almost  useless 
in  circulatory  weakness  resulting  from  causes  outside  the  heart,  and 
is  of  no  use  in  the  toxic  circulatory  disturbance  of  acute  infections. 
Its  chief  indication  is  in  cardiac  insufficiency  from  disease  of  the 
endocardium,  myocardium,  or  pericardium.  In  children  it  is  more 
useful  in  the  treatment  of  chronic  than  of  acute  lesions  of  the  heart, 
and  it  is  particularly  valuable  in  cardiac  disease  associated  with 
edema,  on  account  of  its  diuretic  action.  The  usual  preparation  is 
the  tincture  of  digitalis  (U.  S.  P.).  Indications  for  its  use  are  very 
rare  in  children  under  one  vear.     The  dose  is  as  follows: 


One  to  two  years. 

m.  IT 

Two  to  five  years, 

m.  IV 

Over  five  years, 

m.  V  to  X 

Given  three  times  a  day.     It  is  given  by  mouth. 

The  following  preparations  and  substitutes  for  tincture  of  digi- 
tahs  may  be  used:  Digipuratum,  the  patented  preparation  put  up 
in  tablets  of  which  each  is  equal  in  strength  to  m.  xv.  of  the  tincture. 
It  is  expensive.  Tincture  of  strophanthus  (U.  S.  P.).  The  action  is 
very  similar  to  that  of  the  tincture  of  digitalis  and  it  is  given  in  the 
same  doses.  It  should  be  remembered  that  the  absorption  is  slow 
and  that  twenty-four  hours  or  more  is  required  for  the  drug  to  pro- 
duce a  result.     Excretion  is  slow,  and  action  may  be  cumulative. 


^ 


i 


W"'^ 


mmmm 


1_  , 


Fig.  50 — Tube  feeding,  second  step 


Useful  Drugs  169 

Camphor. — This  is  useful  as  a  rapid  stimulant  in  sudden  circula- 
tory collapse.  It  is  given  only  subcutaneously  or  intravenously  in 
the  form  of  a  lo  per  cent,  solution  in  oil.  The  doses  of  this  solution 
are  as  follows: 


One  to  six  months, 

m.  11 

Six  months  to  a  year, 

m.  Ill 

One  to  two  years, 

m.  V 

Two  to  five  years, 

m.  VII 

Over  five  years, 

m.  X 

Adrenalin. — This  is  occasionally  useful  in  sudden  circulatory  col- 
lapse, especially  when  of  vasomotor  origin.  The  preparation  is  a 
one  to  one  thousand  solution  of  adrenalin  chloride.  Parke,  Davis 
&  Company's  is  a  good  preparation.  It  is  given  only  hypodermically 
or  intravenously.     The  dose  is  as  follows: 


One  to  six  months, 

m.  I 

Six  months  to  one  year. 

m.  II 

One  to  two  years. 

m.  Ill 

Two  to  five  years. 

m.  IV 

Over  five  years. 

m.  V 

Strychnin. — This  is  used  only  rarely  as  a  stimulant  in  early  life, 
in  certain  particular  conditions.  Its  indication  will  be  noted  under 
the  diseases  in  which  it  is  occasionally  useful.  It  is  given  hypoder- 
mically in  the  form  of  strychnin  sulphate.     The  dose  is  as  follows: 

One  to  six  months,  gr.  i/Soo 

Six  months  to  one  year,  gr.  1/500 

One  to  two  years,  gr.  1/300 

Two  to  five  years,  gr.  1/200 

Over  five  years,  gr.  i/ioo  to  1/60 

The OBROMiN- Sodium  Salicylate. — This  is  a  double  salt  of  theo- 
bromin-sodium  and  sodium  salicylate.  "Diuretin"  is  a  trade-name 
of  a  similar  preparation.  It  is  described  in  "New  and  Non-Ofificial 
Remedies,  1914."  Theobromin-sodium  salicylate  is  a  diuretic,  act- 
ing directly  on  the  renal  epithelium.  It  is  slightly  irritating  to  the 
kidneys  and  is  contraindicated  in  acute  nephritis.  Its  toxic  effect 
is  vomiting.  The  chief  indication  in  children  is  in  cardiac  disease 
with  edema. 

To  young  children  who  do  not  mind  the  bad  taste,  the  drug  may 
be  given  in  solution;  to  older  children  it  may  be  given  in  capsules. 
The  dose  is  as  follows: 

One  to  six  months,  gr.  I 

Six  months  to  one  year,  gr.  II 

One  to  two  years,  gr.  Ill 

Two  to  five  years,  gr.  V 

Over  five  years,  gr.  V  to  X 

Given  four  times  a  day  by  mouth. 

A  substitute  having  a  similar  action  is  the  patented  preparation 
known  as  theocin.  It  is  used  in  smaller  doses,  from  one-lifth  to  one- 
half  the  quantity  of  diuretin  being  given  at  a  dose. 


170  Disease  in  Early  Life 

SEDATIVES. — This  group  includes  drugs  whose  principal  action 
is  upon  the  nervous  system.  In  it  are  described  drugs  which  are 
given  for  the  purpose  of  quieting  nervous  excitability,  and  also  drugs 
other  than  the  opiates  which  are  used  for  the  rehef  of  pain,  or  to  pro- 
duce sleep. 

Sodium  Bromide.— The  bromides  are  by  far  the  most  generally 
useful  sedatives  in  infancy  and  childhood.  The  sodium  salt  is  to 
be  preferred  to  the  potassium  or  ammonium  salts  for  use  in  child- 
hood. Owing  to  the  fact  that  the  nervous  system  in  early  Hfe  is 
particularly  hable  to  disturbance  of  function,  sodium  bromide  is 
indicated  in  the  symptomatic  treatment  of  a  great  variety  of  condi- 
tions. It  is  also  indicated  in  the  more  pronounced  forms  of  nervous 
irritability,  such  as  convulsions.  It  is  well  borne  by  children  and  is 
proportionately  less  likely  to  produce  vomiting  than  in  adults.  Toxic 
effects  are  vomiting,  acne,  coryza,  and  somnolence. 

Sodium  bromide  is  administered  in  watery  solution  well  diluted. 
It  is  given  by  mouth  except  in  cases  where  vomiting  is  present  or 
where  swallowing  is  impossible.  Under  the  latter  conditions  it  is 
given  by  rectum.  The  dose  varies  somewhat  with  the  purpose  for 
which  the  drug  is  prescribed.  As  a  sedative  in  comparatively  mild 
conditions,  the  dose  is  as  follows: 

One  to  six  months, 
Six  months  to  one  year, 
One  to  two  years, 
Two  to  five  years, 
Over  five  years, 

given  every  four  hours. 

When  sodium  bromide  is  given  for  the  purpose  of  checking  serious 
symptoms  such  as  convulsions  or  vomiting,  the  doses  must  be  some- 
what larger,  as  follows: 


BY  MOUTH 

BY  RECTUM 

gr.  1/2 

gr.I 

gr.  I-x/2 

gr.II 

£:r.  Ill  to  IV 

gr.I 
gr.II 
gr.  Ill 
gr.  IV 
gr.  VI  to  X 

BY  MOUTH 

BY  RECTUM 

One  to  six  months, 
Six  months  to  one  year, 
One  to  two  years, 
Two  to  five  years, 
Over  five  years. 

gr.  I-1/2 

gr.  II-1/2 

gr.V 

gr.VII 

gr.  X  to  XV 

gr.  Ill 

gr.V 

gr.X 

gr.  XV 

gr.  XX  to  XXX 

Given  as  a  single  dose  and  repeated  as  often  and  in  whatever  doses 
as  are  necessary  to  produce  the  desired  effect. 

Chloral. — The  chief  use  of  chloral  in  early  life  is  to  check  severe 
convulsions  in  infancy.  It  is  well  borne  even  by  quite  young  infants. 
It  should  always  be  given  in  solution  by  rectum.  The  dose  is  as 
follows : 

One  to  three  months,  gr.  I 

Three  to  six  months,  gr.  II 

Six  to  twelve  months,  gr.  Ill 

One  to  two  years,  gr.  V 


Useful  Drugs  171 

Trional. — This  is  occasionally  indicated  in  older  children  for  the 
same  purpose  for  which  it  is  used  in  adults,  namely,  to  produce  sleep. 
Insomnia,  however,  is  a  symptom  which  much  less  often  requires 
treatment  in  children  than  in  adults,  and  is  usually  produced  by  those 
forms  of  nervous  over-excitability  which  are  best  treated  by  the 
administration  of  bromide.  In  infants  trional  is  almost  never  indi- 
cated, sodium  bromide  being  preferred. 

Trional  is  insoluble  and  is  given  by  being  placed  upon  the  tongue 
and  washed  down  with  water.     The  dose  is  as  follows: 

Two  to  five  years,  gr.  II 

Five  to  thirteen  years,  gr.  Ill  to  V 

Salicylate. — This  represents  the  most  useful  drug  for  the  rehef 
of  certain  kinds  of  pain  in  childhood.  In  addition  to  being  anal- 
gesic, sahcylate  is  antipyretic  and  diaphoretic.  It  also  increases 
nitrogen  ehmination  in  the  urine,  acts  as  a  cholagogue,  and  has  some 
diuretic  action.  The  toxic  effects  are  tinnitus,  headache,  vomiting, 
erythema,  and  in  very  large  doses,  drowsiness  or  dehrium.  It  is 
very  well  borne  by  children.  It  is  contraindicated  in  acute  nephritis 
or  when  there  is  an  idiosyncrasy. 

The  indications  for  salicylate  are  rheumatic  fever,  and  various 
other  conditions  belonging  in  the  ill-defined  rheumatic  class  which 
are  characterized  by  pain.  It  is  used  for  pain  in  arthritis,  peri- 
carditis, endocarditis,  neuritis,  neuralgia,  and  similar  conditions. 
It  is  an  open  question  whether  its  action  in  rheumatic  fever  is  only 
to  reheve  pain,  or  whether  it  has  some  actual  curative  action.  There 
is  evidence  that  it  has  curative  value  in  some  cases  of  chorea. 

It  is  comparatively  rarely  used  in  infants,  as  they  do  not  often 
suffer  from  rheumatic  fever  or  from  the  various  forms  of  pain  which 
are  influenced  by  salicylate. 

The  preparation  most  commonly  used  is  the  sodium  sahcylate 
(U.S.P.).  Children  do  not  mind  the  taste  of  sodium  sahcylate  as 
do  adults,  and  consequently  the  drug  is  best  given  in  solution  which 
may  be  so  arranged  that  one  teaspoonful  contains  the  desired  dose. 
It  is  usually  unnecessary  to  add  any  vehicle  for  the  purpose  of  dis- 
guising the  taste.     The  dose  is  as  follows  in  rheumatic  fever: 

Two  to  five  years,  gr.  Ill 

Five  to  eight  years,  ■  gr.  V 

Eight  to  thirteen  years,  gr.  V  to  VII 

Given  every  hour  until  relief  of  pain  has  appeared,  and  after  this 
every  four  hours,  unless  some  toxic  effect  is  produced.  For  pain  in 
other  concUtions  than  rheumatic  fever  smaller  doses  may  be  sufficient, 
A  common  substitute  for  sodium  salicylate  is  acetylsalicylic  acid 
which  is  a  proprietary  preparation  sold  under  the  trade  name  of 


172  Disease  in  Early  Life 

aspirin.     In  children  this  has  no  particular  advantage  over  sodium 
salicylate.     The  doses  are  the  same. 

Phenacetin. — This  was  formerly  a  proprietary  preparation,  but 
it  is  now  official  under  the  name  of  acetphenetidinum.  It  is  a  coal-tar 
derivative.  Its  action  is  analgesic,  antipyretic,  mild  diaphoretic, 
and  sedative.  The  toxic  effect  is  circulatory  depression,  but  it  is 
comparatively  well  borne  by  children.  It  is  used  in  a  great  variety 
of  conditions,  rarely  as  an  antipyretic,  more  often  as  an  analgesic 
or  sedative. 

Phenacetin  has  the  disadvantage  of  being  insoluble,  and  is  given 
in  tablet  form  or  as  a  powder.     The  dose  is  as  follows: 


One  to  six  months, 

gr-  1/4 

Six  months  to  one  year, 

gr.  1/2 

One  to  two  years, 

gr.I 

Two  to  five  years, 

gr.  I-1/2  to  II 

Over  five  years, 

gr.  II  to  IV 

Repeated  every  two  to  four  hours  until  the  desired  effect  is  produced. 

OPIATES. — Strong  objections  have  been  urged  against  the  use 
of  opium  in  the  diseases  of  early  life.  It  is  true  that  the  opiates  are 
less  often  required  in  infancy  and  childhood  than  in  adult  life,  and 
this  apphes  especially  to  infancy.  Nevertheless,  cases  are  frequently 
encountered  in  which  an  opiate  is  required  for  the  relief  of  pain. 
Moreover,  small  doses  of  an  opiate  are  the  most  effective  means  which 
we  have  of  controlling  excessive  cough. 

Paregoric. — This  is  the  most  generally  useful  preparation  of 
opium  for  use  in  young  children.  Its  chief  uses  are  to  check  cough, 
check  certain  forms  of  diarrhea,  and  occasionally  to  control  pain. 
The  doses  are  as  follows: 


One  to  three  months, 

m.  I 

Three  to  six  months, 

m.  II 

Six  months  to  one  year. 

m.  Ill 

One  to  two  years, 

m.  V 

Two  to  five  years, 

m.  X  to  XX 

Five  to  ten  years, 

m.  XX  to  XXX 

Given  every  four  hours  by  mouth  in  a  little  water. 

MORPHIN.— This  is  the  best  preparation  of  opium  for  the  control 
of  severe  pain.  It  is  not  well  borne  by  children  and  the  doses  must 
be  proportionately  smaller.  Morphin  is  most  commonly  given  hypo- 
dermically  in  the  following  doses: 

One  to  three  months,  gr.  1/1500 

Three  to  six  months,  gr.  i/iooo 

Six  months  to  one  year,  gr.  1/600 

One  to  two  years,  gr.  1/300 

Two  to  five  years,  gr.  i/ioo  to  1/48 

Five  to  ten  years,  gr.  1/48  to  1/24 

Over  ten  years,  gr.  1/24  to  1/12 


Useful  Drugs  173 

Repeat  when  necessary,  not  sooner  than  in  two  hours.     When  given 
by  mouth  the  doses  must  be  slightly  larger. 

CoDEiN. — This  opium  derivative  is  chiefly  employed  for  cough, 
or  for  the  treatment  of  pain.  It  is  less  effective  than  morphin  but 
does  not  have  the  constipating  effect.     The  dose  is  as  follows: 

One  to  three  months,  gr.  1/300 

Three  to  sLx  months,  gr.  1/200 

Six  months  to  one  year,  gr.  i/ioo 

One  to  two  years,  gr.  1/60 

Two  to  five  years,  gr.  1/60  to  i/io 

Five  to  ten  years,  gr.  i/io  to  1/8 

Over  ten  years,  gr.  1/8  to  1/6 

Given  by  mouth  and  repeated  when  necessary,  or  every  four  hours. 

Dover's  Powder. — This  is  occasionally  used  instead  of  pare- 
goric, and  for  the  same  indications.     The  dose  is  as  follows: 


One  to  three  months, 

gr- 

I   20 

Three  to  six  months, 

gr. 

i/io 

Six  months  to  one  year, 

gr- 

1/8 

One  to  two  years. 

gr- 

1/4 

Two  to  five  years. 

gr- 

1/2  to  I 

Five  to  ten  years, 

gr- 

II  to  III 

Over  ten  years, 

gr- 

III  to  IV 

PURGATIVES  AND  LAXATIVES.  Castor  Oil  (Oleum  ricini 
U.S. P.). — This  is  the  most  useful  general  purgative  for  use  in  infancy 
and  childhood.  Nothing  surpasses  it  in  producing  rapid  and  complete 
emptying  of  the  bowels.  Its  chief  indication  is  in  various  forms  of 
indigestion,  especially  those  characterized  by  diarrhea.  Infants 
and  very  young  children  do  not  object  to  the  taste,  and  even  older 
children  will  often  not  mind  the  taste  if  it  has  not  been  suggested  to 
them  that  the  taste  is  bad.  When  the  taste  is  objected  to,  castor  oil 
may  be  given  with  orange  juice,  lemon  juice,  or  brandy.  The  doses 
are  as  follows: 

First  year,  i  teaspoonful 

Second  year,  2  teaspoonfuls 

Two  to  five  years,  3  teaspoonfuls 

Over  five  years,  i  tablespoonful 

Calomel. — This  is  a  purgative  and  diuretic,  but  in  children  is 
used  almost  wholly  on  account  of  its  purgative  action.  The  toxic 
effects  are  renal  irritation  and  stomatitis,  but  the  purgative  doses 
used  with  children  never  produce  these  effects. 

Calomel  is  useful  as  a  substitute  for  castor  oil  when  vomiting  is 
present,  and  is  also  useful  in  the  treatment  of  vomiting,  as  when 
given  in  repeated  doses  it  tends  to  correct  reversed  peristalsis.  It  is 
dispensed  in  the  form  of  tablets  or  powders.  When  tablets  are  given 
they  should  be  crushed  into  powder  with  the  back  of  a  teaspoon, 
and  the  powder  is  given  by  being  floated  on  the  surface  of  a  teaspoonful 


174  Disease  ix  Early  Liee 

of  water.     In  almost  all  cases  calomel  is  best  given  to  children  in 
dix-ided  doses  as  follows: 

One  to  six  months,  gr.  1/20,  even'  half  hour  for  ten  doses 

Six  months  to  two  years,  gr.  i/io,  every  hah"  hour  for  ten  doses 

Two  to  five  years,  gr.  1/8,    every  half  hour  for  ten  doses 

Over  five  years,  gr.  1/4,    ever}'  half  hour  for  eight  doses 

In  infants  it  is  unnecessary  to  follow  the  calomel  with  a  saline 
cathartic.  In  older  children  it  is  well  to  follow  it  with  a  dose  of 
magnesia. 

Magnesia. — This  is  the  most  useful  mild  laxative  for  use  in  infancy 
and  childhood.  In  the  first  two  years  of  Ufe  the  best  preparation 
is  PhiUips'  milk  of  magnesia.  After  two  years  the  best  preparation 
is  citrate  of  magnesia. 

Milk  of  magnesia,  which  is  a  suspension  in  water,  is  used  in  infancy 
for  two  purposes.  The  first  is  as  a  mild  measure  for  the  emptying 
of  the  bowels.     The  dose  is  as  follows: 

One  to  six  months,  i  teaspoonful 

Six  months  to  one  year,  2  teaspoonfuls 

One  year  to  eighteen  months,  3  teaspoonfuls 

Eighteen  months  to  two  years,  i  tablespoonful 

The  other  use  for  milk  of  magnesia  is  in  the  treatment  of  constipa- 
tion. For  this  purpose  it  is  better  not  to  give  the  magnesia  in  single 
daily  doses,  but  to  give  it  with  every  feeding.  The  dose  required 
varies  with  the  severity  of  the  case  and  mil  be  discussed  under  con- 
stipation. 

In  children  over  two  years  of  age  citrate  of  magnesia  is  the  best 
preparation.     The  dose  is  as  follows:' 

Two  to  five  years,  oz.  11 

Over  five  years,  oz.  IV 

Given  usually  at  bedtime. 

Magnesium  Sulphate. — This  is  occasionally  used  in  childhood 
as  a  hydrogogue  purge.  Its  chief  indication  is  in  dropsy,  whether 
of  cardiac  or  of  renal  origin.  It  is  contraindicated  when  there  is 
marked  weakness,  emaciation,  or  vomiting.  The  dose  in  young 
children  is  two  teaspoonfuls,  in  older  children  two  to  four  teaspoon- 
fuls, given  well  diluted  in  water  on  an  empty  stomach. 

Casc-AJRA. — (Fluldextractum  Rhamni  purshianae,  U.S. P.).  (Fluid 
Extract  of  Cascara  Sagrada).  This  is  a  mild  laxative  useful  in  con- 
stipation and  in  a  variety  of  other  conditions  as  a  means  of  keeping 
the  bowels  open.  It  is  not  so  good  in  the  treatment  of  constipation 
in  infants  as  in  older  children.  The  dose  in  infants  is  from  one  to 
five  drops,  in  older  children  from  five  to  twenty  drops.  It  is  given 
in  water,  preferably  at  bedtime. 


Useful  Drugs  175 

Agar  Agar. — This  substance  swells  enormously  by  the  absorption 
of  water,  is  not  digested,  does  not  ferment,  and  is  consequently  useful 
in  stimulating  peristalsis  and  sweeping  out  the  intestine.  It  is  used 
in  chronic  constipation  usually  in  conjunction  with  other  forms  of 
treatment.  The  dose  is  from  a  teaspoonful  to  a  tablespoonful  once 
or  twice  daily.  Powdered  agar  agar  may  be  eaten  on  cereal.  Granu- 
lated agar  agar  may  be  eaten  mixed  with  milk  or  water.  There  are 
also  agar  agar  wafers  on  the  market. 

Russian  Oil. — This  is  liquid  paraffin  similar  to  the  petrolatum 
liquidum  of  the  U.S. P.  The  Russian  oil  is,  however,  a  more  refined 
product  and  does  not  have  the  yellowish  color  and  unpleasant  taste 
which  characterizes  American  petroleum.  It  is  useful  as  an  intestinal 
lubricant  which  passes  unabsorbed  and  undigested  through  the 
intestine.  It  is  employed  in  some  cases  of  chronic  constipation. 
The  doses  are  as  follows: 

Under  two  years,  i  teaspoonful 

Two  to  five  years,  2  teaspoonfuls 

Five  to  ten  years,  2  to  4  teaspoonfuls 

Given  three  times  daily  after  meals. 

TONICS.  Alcohol. — This  is  well  tolerated  by  children,  even 
by  young  infants.  It  has,  however,  been  much  abused  through 
being  used  as  a  stimulant.  The  chief  value  of  alcohol  in  early  life 
is  as  a  tonic,  particularly  in  conditions  of  malnutrition.  It  is  useful 
in  many  chronic  conditions,  and  in  acute  febrile  conditions  late  in  the 
course  of  the  disease.  Alcohol  is  best  administered  to  children  in 
the  form  of  brandy  or  whisky.  The  twenty-four  amounts  with  which 
treatment  with  brandy  is  begun  in  children  are  as  follows: 

One  to  six  months,  1/2  teaspoonful 

Six  to  twelve  months,  i  teaspoonful 

One  to  two  years,  2  teaspoonfuls 

Two  to  five  years,  3  to  4  teaspoonfuls 

Over  five  years,  4  to  6  teaspoonfuls 

This  may  be  given  in  divided  doses  with  the  feedings  or  meals. 

Iron. — This  is  as  useful  as  a  tonic  in  the  anemias  of  infancy  and 
childhood  as  it  is  in  those  of  adults.  The  best  preparation  for  use 
in  the  anemias  of  infancy  is  the  citrate  of  iron  given  subcutaneously. 
An  aqueous  solution  of  the  citrate  is  put  up  in  ampules,  sterilized,  and 
each  ampule  contains  a  single  dose.  A  platinum  needle  must  be  used. 
The  dose  during  infancy  is  three-quarters  of  a  grain  every  other  day. 

An  alternative  preparation  for  use  in  infancy  is  the  saccharated 
carbonate  in  doses  of  5  gr.  three  times  a  day.  With  older  children 
nothing  is  better  than  Blaud's  pills  in  doses  of  5  gr.  three  times  a  day. 

Arsenic. — This  is  indicated  as  a  tonic  in  a  variety  of  conditions 
encountered  in  infancy  and  childhood.     It  is  usually  given  in  the 


176  Disease  in  Early  Life 

form  of  Fowler's  solution  (liquor  potassii  arsenitis,  U.S. P.).  Arsenic 
is  well  borne  by  children.  The  doses  of  Fowler's  solution  for  ordinary 
tonic  purposes  are  as  follows: 

One  to  six  months,  i  drop  once  a  day- 
Six  to  twelve  months,  i  drop  twice  a  day 
One  to  two  years,  i  drop  three  times  a  day 
Two  to  five  years,  2  drops  three  times  a  day 
Over  five  years,  2  to  5  drops  three  times  a  day 

Given  in  w^ater  after  meals. 

Cod  Liver  Oil.  (Oleum  Morrhuae,  U.S. P.). — This  is  a  very 
useful  tonic  in  infancy  and  childhood,  used  in  a  variety  of  conditions. 
In  the  case  of  infants,  the  pure  oil  is  to  be  preferred  to  an  emulsion. 
The  dose  is  10  to  20  drops  three  times  a  day  after  meals.  To  older 
children  any  good  emulsion  of  cod  hver  oil  may  be  given  in  doses  of 
I  to  4  teaspoonfuls  three  times  a  day  after  meals. 

Malt  Preparations. — These  are  sometimes  of  value  as  tonics, 
particularly  in  conditions  in  which  cod  liver  oil  is  not  well  borne. 
Malt  extract  may  also  often  be  advantageously  combined  with  cod 
liver  oil.  The  dose  is  i  to  4  teaspoonfuls  three  times  a  day  after 
meals. 

Tincture  of  Nux  Vomica. — This  is  the  only  bitter  tonic  which  is 
much  used  in  the  diseases  of  early  Hfe.  It  is  especially  useful  in  con- 
ditions attended  with  loss  of  appetite.     The  dose  is  as  follows: 


One  to  six  months. 

m.  1/4 

Six  months  to  one  year. 

m.  1/2 

One  to  two  years, 

m.  I 

Two  to  five  years. 

m.  II 

Over  five  j^ears. 

m.  Ill  to  V 

Given  three  times  a  day  before  meals. 

It  may  be  combined  with  water  in  such  proportions  that  each  tea- 
spoonful  contains  the  required  dose. 

Compound  Syrup  of  the  Hypophosphites.  (Syrupus  Hypophos- 
phitum  Compositus,  U.S.P.).— This  is  occasionally  useful  as  a  tonic 
in  older  children.  The  dose  is  i  teaspoonful  three  times  a  day  after 
meals. 

DRUGS  USED  UNDER  SPECIAL  INDICATIONS.  Sal- 
VARSAN. — This  is  a  proprietary  preparation.  Its  action  is  to  kiU  cer- 
tain pathogenic  organisms  in  the  living  body.  It  may  irritate  the 
kidneys  or  liver,  but  apparently  has  no  toxic  effect  for  other  organs. 
Its  toxic  effects  are  as  follows :  Signs  of  renal  irritation  or  diminution 
of  renal  function;  jaundice;  erythema;  hyperemia  and  swelling  at 
the  site  of  the  syphilitic  lesions;  fever  developing  gradually. 

The  only  indication  for  salvarsan  in  infancy  and  childhood  is 
syphilis. 


Useful  Drugs  177 

Neosalvarsan  has  an  action  like  that  of  salvarsan  but  less  powerful 
in  equal  dosage,  and  with  less  danger  of  toxic  effects.  The  dose  of 
salvarsan  for  an  infant  is  0.05  gm.;  the  dose  of  neosalvarsan  is  o.i  gm. 
The  method  of  administering  salvarsan  will  be  described  under 
syphilis. 

Mercury. — This  is  used  in  early  life  in  the  treatment  of  congenital 
syphiUs.  Mercury  is  usually  given  to  infants  by  inunction.  Equal 
parts  of  unguentum  hydrargyri  and  vaselin  are  ordered,  and  an  amount 
the  size  of  a  pea  is  rubbed  in  daily.  If  for  any  reason  the  inunctions 
are  objectionable,  the  gray  powder  (hydrargyri  cum  creta,  U.S. P.) 
may  be  given  by  mouth.     The  dose  is  gr.  1/2  three  times  a  day. 

PoTASSii  loDiDUM. — lodide  of  potash  has  two  actions  of  impor- 
tance in  the  therapeutics  of  infancy  and  childhood.  These  are:  i.  It 
causes  the  disappearance  of  the  tertiary  lesions  of  syphilis.  2.  It 
increases  the  fluidity  of  mucus  in  the  respiratory  tract.  In  over 
doses  it  causes  acne,  catarrh  of  the  respiratory  organs,  gastric  dis- 
turbance, and  possibly  dehrium.  Its  chief  indications  are  in  tertiary 
syphilis,  in  bronchitis  with  sticky  expectoration,  and  empirically 
in  asthma. 

lodide  of  potash  is  well  borne  by  children,  and  for  tertiary  syphihs 
may  be  given  to  older  children  in  the  same  doses  as  to  adults,  namely, 
10  to  20  gr.  three  times  a  day.  In  infancy  the  usual  dose  iri  syphilis 
is  5  gr.  three  times  a  day.  As  an  expectorant  the  doses  are  half  those 
given  for  syphilis.  Usually,  however,  as  an  expectorant  in  infancy 
and  childhood,  it  is  better  to  use  as  a  substitute  syrup  of  hydriodic 
acid.     The  doses  are  as  follows: 

One  to  six  months,  5  drops  three  times  a  day 

Six  months  to  one  year,  lo  drops  three  times  a  day 

One  to  two  years,  15  drops  three  times  a  day 

Two  to  five  years,  20  drops  three  times  a  day 

Over  five  years,  1/2  teaspoonful  three  times  a  day 

QuiNiN. — This  is  a  specific  for  malaria.  It  is  well  borne  by  young 
children  and  relatively  larger  doses  are  required  than  for  adults. 
The  various  preparations  of  quinine,  the  doses,  and  the  methods 
of  administration  will  be  described  in  detail  under  malaria. 

Hexamethylenamin. — This  drug  is  excreted  in  an  acid  urine 
in  the  form  of  ammonia  and  formaldehyde.  The  setting  free  of  for- 
maldehyde acts  as  a  urinary  antiseptic.  When  the  urine  is  alkahne 
or  neutral  in  reaction,  hexamethylenamin  is  excreted  unchanged, 
and  is  inefhcient.  In  such  a  case  the  urine  should  be  made  acid  by 
the  administration  of  acid  sodium  phosphate,  but  this  drug  should 
not  be  administered  with  hexamethylenamin  because  they  are  in- 
compatible. 

Hexamethylenamin  is  especially  indicated  in  pyelitis  and  cystitis; 
12 


178  Disease  IN  Early  Life 

also  in  typhoid  fever,  to  prevent  bacilluria  and  cystitis.  The  dose 
is  as  follows: 

One  to  six  months,  gr.  II     three  times  a  day 

Six  months  to  one  year,  gr.  Ill  three  times  a  day 

One  to  two  years,  gr.  V     three  times  a  day 

Two  to  five  years,  gr.  VII  three  times  a  day 

Over  five  years,  gr.  X     three  times  a  day 

The  drug  is  given  in  solution  which  may  be  so  put  up  that  a  teaspoon- 
ful  contains  the  required  dose.     It  should  be  given  with  plenty  of  water. 

''Uro tropin,"  "formin,"  and  "aminoformin,"  are  proprietary  names 
applied  to  hexamethylenamin. 

Sodium  Bicarbonate. — This  is  used  in  infancy  and  childhood  in  a 
great  variety  of  conditions,  among  which  are  the  following:  (i)  In 
the  modification  of  cow's  milk  for  infant  feeding;  (2)  as  an  antacid 
acting  locally  in  certain  disturbances  of  digestion;  (3)  as  a  means  of 
making  the  urine  alkahne;  (4)  as  a  means  of  diminishing  the  acidity 
of  the  blood.  The  dosage  and  method  of  administering  vary  widely 
with  the  different  purposes  for  which  bicarbonate  of  soda  is  used, 
and  will  be  given  under  the  various  indications. 

Bismuth  Subnitrate. — This  a  mild  astringent  and  antacid,  and 
combines  with  the  sulphuretted  hydrogen  in  the  intestine  to  form  a 
black  insoluble  sulphate.  In  childhood  it  is  chiefly  used  in  the  treat- 
ment of  certain  forms  of  diarrhea.  A  good  preparation  for  infants 
is  the  milk  of  bismuth  (Parke,  Davis  and  Co.),  which  can  be  given  in 
the  feedings;  each  teaspoonful  contains  5  gr.  of  bismuth  subnitrate. 
The  doses  are  as  follows:  Infants,  gr.  V.  Older  children,  gr.  X. 
Given  every  four  hours,  or  repeated  after  each  loose  movement. 

Potassium  Chlorate. — This  is  chiefly  used  in  the  treatment  of 
certain  forms  of  stomatitis  in  infancy  and  early  childhood.  Its  bene- 
ficial effect  comes  from  the  fact  that  it  is  almost  wholly  excreted  with 
the  saliva.  When  given  in  over-doses,  it  is  toxic,  the  symptoms  being 
drowsiness,  suppression  of  urine,  cardiac  weakness,  and  sometimes 
cyanosis.  The  best  method  of  administering  it  is  to  put  the  entire 
twenty-four  hour  amount  into  a  glass  of  water,  and  to  divide  the 
doses  in  such  a  way  that  they  will  be  given  as  frequently  as  possible. 
The  following  is  the  quantity  which  can  be  taken  in  twenty-four  hours 
at  the  different  ages: 

Under  one  year,  gr.  X 

One  to  two  years,  gr.  XV 

Two  to  six  years,  gr.  XX 

Six  to  eight  years,  gr.  XXV 

Eight  to  fourteen  years,  gr.  XXX 

Sweet  Spirits  of  Nitre.  (Spiritus  aetheris  nitrosi). — This  is 
used  in  infants  as  a  mild  diuretic  and  antipyretic.  The  doses  are  as 
follows : 


Useful  Dr 

tJGS 

One  to  six  months, 
Six  months  to  one  year, 
One  to  two  years, 
Two  to  five  years, 
Over  five  years, 

m.  II 

m.  Ill 

m.  V 

ra.  X 

m.  XV  to  XX 

179 


Given  every  four  hours  in  water. 

Ipecac. — This  drug  is  used  in  infancy  and  childhood  chiefly  as  an 
expectorant,  but  occasionally  as  an  emetic.  Its  chief  value  is  in 
croup.  The  best  preparation  for  children  is  the  Wine  of  Ipecac. 
Expectorant  doses  are  as  follows: 


One  to  three  months. 

m.  1/4 

Three  to  six  months, 

m.  1/2 

Six  months  to  one  year, 

m.I 

One  to  two  years, 

m.  II 

Two  to  five  years, 

m.  Ill 

Over  five  years. 

m.  V 

Given  every  four  hours  in  a  little  water. 

As  an  emetic  or  in  croup,  larger  doses  are  required. 

Sodium  Benzoate. — This  is  occasionally  used  in  early  life,  par- 
ticularly in  the  treatment  of  pyelitis.  The  purpose  of  its  adminis- 
tration is  to  make  the  urine  acid.  The  dose  in  infancy  is  i  to  5  gr. ; 
in  older  children,  5  to  30  gr.     It  is  given  in  solution. 

Potassium  Acetate. — This  is  occasionally  used  in  early  life,  chiefly 
for  the  purpose  of  making  the  urine  alkaline.  The  doses  are  the  same 
as  those  of  sodium  benzoate. 

Atropin  and  Belladonna. — The  chief  use  of  this  drug  in  early 
life  is  in  the  treatment  of  enuresis.  The  dosage  and  method  of  ad- 
ministration will  be  described  under  that  disease.  Atropin  and  bella- 
donna are  occasionally  used  for  their  action  in  checking  excessive 
secretion  from  the  respiratory  mucous  membrane.  Atropin  is 
also  used  with  morphin  for  its  counteracting  effect.  The  doses 
are  as  follows: 


For  Atropin— 

One  to  three  months, 

gr.  1/5000 

Three  to  six  months, 

gr.  1/3000 

Six  months  to  one  year, 

gr.  1/2000 

One  to  two  years. 

gr.  i/iooo 

Two  to  three  years, 

gr.  1/500 

Three  to  five  years. 

gr.  1/300 

Five  to  seven  years. 

gr.  1/200 

Seven  to  ten  years. 

gr-  1/150 

Ten  to  fourteen  years. 

gr.  i/ioo 

For  Tincture  of  Belladonna — 

One  to  six  months, 

m.  1/4 

Six  months  to  one  year, 

m.  1/2 

One  to  two  years. 

m.I 

Two  to  three  years. 

m.  II 

Three  to  five  years. 

m.  Ill 

Five  to  seven  years, 

m.  V 

Seven  to  ten  years, 

m.  VII 

Ten  to  fourteen  years, 

m.X 

180  Disease  in  Early  Life 

Thyroid  Extract. — This  is  used  in  infancy  in  the  treatment  of 
cretinism.  There  are  various  preparations,  among  which  I  have 
found  that  of  Burrough's  and  Welcome  to  be  very  satisfactory  The 
doses  should  be  at  first  gr.  1/4  three  times  a  day,  and  this  is  gradu- 
ally increased.  Signs  of  over-dosage  are  wakefulness,  sweating, 
tachycardia,  or  rise  of  temperature. 

ROUTINE  TREATMENT  OF  AN  ACUTE  SELF- 
LIMITED  DISEASE 

In  order  to  avoid  needless  repetition  in  the  description  of  the  treat- 
ment of  various  diseases,  the  routine  treatment  of  an  acute  self- 
limited  disease  will  be  described  here.  It  will  then  only  be  necessary 
in  the  description  of  the  particular  diseases  of  this  class  to  enumerate 
any  special  modifications  called  for  by  the  special  etiology  and  symp- 
toms of  the  several  diseases.  The  duty  of  the  physician  in  an  acute 
self-limited  disease  may  be  summarized  as  follows: 

1.  The  hygienic  care  of  the  patient. 

2.  Directing  the  diet. 

3.  Attending  to  the  bowels. 

4.  The  treatment  of  symptoms. 

5.  Watching  for  complications. 

To  these  may  be  added  in  certain  diseases — 

6.  The  establishment  of  quarantine  and  the  carrying  out  of  proper 
means  of  disinfection. 

Hygienic  Care. — Children  with  an  acute  self-limited  disease 
should  invariably  be  kept  in  bed  during  the  entire  febrile  period,  and 
for  a  certain  time  after  the  fever  has  subsided.  The  length  of  time 
during  which  they  should  be  kept  in  bed  after  the  temperature  has 
come  down  permanently  to  the  normal  varies  with  the  several  dis- 
eases. The  sick-room  should  preferably  be  one  with  a  sunny  exposure. 
Plenty  of  fresh  air  should  always  be  secured  at  all  times.  In  winter 
an  open  fire  in  the  sick-room  is  very  desirable. 

Every  detail  of  the  nursing  should  be  carefully  supervised,  and 
good  nursing  is  the  prime  essential  in  the  treatment  of  the  acute 
febrile  diseases.  It  is  usually  best  for  the  child  not  to  walk  or  be 
carried  to  the  bathroom,  but  to  remain  continuously  in  bed,  using 
the  bedpan.  Sponge  baths  should  be  given  in  bed.  Plenty  of  water 
should  be  given  in  all  febrile  diseases. 

The  management  of  convalescence  is  important.  The  time  when 
the  child  is  allowed  to  get  out  of  bed  depends  mainly  on  the  rapidity 
with  which  its  strength  returns,  and  varies  with  the  character  and 
severity  of  the  disease.  It  is  usually  best  to  keep  children  in  bed 
for  some  time  after  they  are  anxious  to  get  up,  even  though  recovery 


Routine  Treatment  181 

in  children  is  usually  rapid.  Patients  should  first  be  allowed  to  sit 
up  in  bed  for  an  increasing  length  of  time  each  day.  They  may  then 
be  allowed  to  sit  up  in  a  chair  for  a  little  while  in  their  dressing  gowns, 
and  if  this  does  not  tire  them,  they  may  be  given  their  clothes.  On 
the' first  day  after  a  child  gets  its  clothes,  it  should  not  be  allowed  to 
walk  farther  than  from  the  bed  to  a  chair,  and  should  only  be  dressed 
for  a  short  time.  As  the  strength  of  the  child  increases,  it  may  be 
allowed  to  be  dressed  for  a  longer  period  each  day,  and  to  gradually 
walk  about  more.  When  the  child  shall  be  allowed  to  go  out  doors 
depends  upon  the  rapidity  of  the  return  of  strength  and  upon  the 
prevailing  weather  conditions. 

The  Diet. — The  diet  to  be  given  in  acute  febrile  diseases  varies 
somewhat  with  the  type  of  infection.  In  breast-fed  babies  no  change 
should  be  made  from  the  normal  diet,  except  possibly  shght  dilution 
of  the  breast  milk  by  giving  boiled  water,  or  water  and  hme  water 
immediately  before  each  nursing.  In  artificially-fed  infants,  it 
should  be  remembered  that  in  acute  febrile  diseases  the  digestive 
power  is  lowered.  Consequently  the  composition  of  the  food  must 
be  adapted  to  the  digestive  power  of  the  child  by  a  reduction  in  the 
percentages  of  all  the  food  elements,  and  fat  is  especially  badly  borne 
in  acute  illness.  On  the  other  hand,  the  child  should  be  fed  up  to  the 
limit  of  its  digestive  power.  The  feeding  must  be  carried  out  on  the 
principle  described  in  the  division  on  Feeding.  It  is  unnecessary 
under  ordinary  circumstances  to  change  the  amounts  given  at  a  feed-, 
ing  and  the  intervals  between  feedings. 

Older  children  with  acute  febrile  diseases  must  be  fed  more  fre- 
quently with  smaller  quantities  than  in  health,  the  usual  interval 
being  every  four  hours  during  the  day,  and  sometimes  an  additional 
night  feeding  is  given. 

Children  should  always  be  fed  at  regular  intervals,  should  never 
be  fed  oftener  than  every  three  hours,  and  should  never  be  given  milk 
between  feedings  when  they  ask  for  a  drink.  The  diet  should  consist 
mainly  of  farinaceous  food.  In  children  under  five  years  of  age,  the 
milk  must  usually  be  somewhat  diluted  with  water  or  lime  water. 
When  children  do  not  take  milk  readily,  they  may  be  given  Kumyss, 
beef  juice,  or  broth,  as  substitutes.  Broth  and  beef  juice  are  also 
often  a  valuable  part  of  the  routine  diet  in  addition  to  the  milk  and 
farinaceous  foods,  when  they  can  be  digested.  Ice  cream  and  jellies 
are  likely  to  disturb  the  stomach  and  should  not  be  given.  Raw  eggs 
beaten  up  with  a  Httle  sherry,  a  little  sugar,  and  cracked  ice  are 
usually  taken  weh,  and  form  a  valuable  addition  to  the  diet.  Orange 
juice  or  grape  juice  may  be  given  with  feedings  at  which  no  milk  is 
taken.  Among  the  farinaceous  foods,  oatmeal  and  barley  gruels  are 
the  best. 


182  Disease  in  Early  Life 

The  physician  should  note  carefully  the  total  amount  of  food  taken 
each  day.  It  is  undesirable  to  force  food  upon  children  who  have 
marked  loss  of  appetite.  In  an  acute  febrile  disease,  anorexia  is 
Nature's  method  of  protecting  the  patient  against  disturbance  of 
digestion.  On  the  other  hand,  anorexia  may  be  so  extreme  that  an 
insufficient  amount  of  food  is  taken.  If  this  occurs  only  during  the 
first  one  or  two  days  of  the  illness,  no  attention  need  be  paid  to  it, 
even  if  practically  no  food  be  taken.  If,  however,  it  continues  longer 
than  the  first  two  days,  forced  feeding  may  be  necessary.  In  such 
cases  gavage  must  be  resorted  to.  Gavage  is  most  often  indicated 
in  infants,  but  is  occasionally  required  in  older  children  also.  If, 
however,  in  older  children  insufficient  food  is  taken  on  account  of 
anorexia  rather  than  on  account  of  delirium  or  coma,  an  effort  should 
be  made  to  increase  the  amount  of  food  taken  by  persuasion,  before 
resorting  to  gavage. 

The  Bowels. — The  nurse  should  be  directed  to  give  an  enema 
every  other  day  as  a  routine,  if  the  bowels  do  not  move.  When  the 
physician  finds  that  these  enemata  are  required,  he  should  order  a 
mild  laxative  to  be  given  daily,  provided  that  it  does  not  upset  the 
stomach.     Magnesia,  or  some  mild  saline  may  be  used  for  this  purpose. 

It  is  usually  a  good  plan  to  empty  the  bowels  at  the  onset  of  an 
acute  febrile  disease.  For  this  purpose  castor  oil  is  best;  if  there  is 
vomiting,  calomel  should  be  used. 

The  Treatment  of  Syimptoms. — As  there  is  no  specific  drug  treat- 
ment for  the  acute  febrile  diseases,  no  drug  should  be  given  as  a  routine. 
The  majority  of  cases  of  acute  febrile  disease  in  children  require  no 
drug  treatment  whatever.  It  is,  however,  very  commonly  said  that 
it  is  difficult  in  private  practice  to  retain  the  confidence  of  the  par' 
ents  of  the  patient  if  no  medicine  is  given.  They  do  not  reahze  that 
the  hygienic  care,  nursing,  and  attention  to  the  diet  and  bowels  are 
the  chief  essentials  of  treatment,  and  feel  that  if  nothing  is  prescribed, 
nothing  is  being  done  for  the  child.  In  my  experience,  the  old  super- 
stition as  to  the  necessity  of  medicinal  treatment  is  gradually  passing 
away;  the  modern  mother  of  the  educated  classes,  in  this  community 
at  least,  often  not  only  knows  that  routine  medicinal  treatment  is 
not  necessary,  but  is  even  apt  to  judge  any  physician  who  uses  it  as 
old  fashioned  and  behind  the  times.  I  realize,  however,  that  among 
many  classes  of  people,  and  in  other  communities,  the  parents  of  sick 
children  demand  drugs.  In  such  cases  the  physician  should  take 
care  to  prescribe  nothing  which  can  possibly  do  any  harm.  Sweet 
spirits  of  nitre  in  small  doses  will  sometimes  satisfy  the  parents.  On 
the  other  hand,  the  physician  should  watch  most  carefully  for  every 
symptom  which  does  require  treatment,  or  which  can  be  benefited  in 
any  way  by  treatment.     When  such  symptoms  arise,  the  proper  treat- 


Routine  Treatment  183 

ment  should  be  instituted  at  once.  Even  in  these  cases,  however,  the 
various  therapeutic  measures  other  than  drugs  are  usually  of  the 
greatest  value. 

Complications. — The  physician  should  watch  most  carefully  for 
the  appearance  of  complications,  as  they  are  not  uncommon  in  the 
acute  febrile  diseases.  An  adequate  physical  examination  should 
never  be  neglected  at  any  visit.  One  of  the  chief  dangers  in  the  acute 
self-limited  diseases  is  the  liability  to  complication,  and  their  early 
recognition  and  proper  treatment  is  of  the  first  importance. 

Quarantine  and  Disinfection. — The  measures  used  in  preventing 
the  transmission  of  the  infection  to  other  persons  will  be  described 
under  the  contagious  diseases. 

ROUTINE  TREATMENT  OF  A  CHRONIC  DISEASE 

In  many  chronic  diseases  it  is  not  necessary  for  the  child  to  be  kept 
in  bed.  Whether  or  not  bed  is  necessary  depends  entirely  upon  the 
patient's  strength.  Chronic  cases  should  have  as  much  open  air 
treatment  as  possible,  and  whenever  weather  conditions  permit,  the 
child  should  be  taken  out  doors  or  its  bed  should  be  placed  out  doors. 
The  hygienic  measures  applicable  to  chronic  diseases  are  the  same 
as  those  indicated  for  the  healthy  child,  with  whatever  modifications 
may  be  demanded  by  the  character  of  the  disease.  The  same  is  true 
of  the  diet.  In  my  experience,  many  children  with  chronic  disease 
are  kept  in  bed  too  much. 


DIVISION  III 


DISEASES  OF  THE  NEWBORN 
I.     MALFORMATIONS 

The  commonest  diseased  conditions  seen  in  newborn  infants  are 
the  various  gross  developmental  lesions  known  as  malformations. 
The  malformations  are  so  very  numerous,  that  their  detailed  descrip- 
tion would  occupy  much  space.  Almost  any  part  of  the  body  may 
be  involved.  Usually  the  malformation  is  external,  and  its  nature 
is  recognizable  at  once.  The  only  question  which  confronts  the 
physician  is  whether  the  condition  is  one  which  offers  hope  of  relief 
through  surgical  treatment.  Occasionally,  the  malformation  is 
internal,  and  gives  rise  to  symptoms  of  functional  disturbance  of  so 
vague  a  character  that  a  diagnosis  cannot  be  made  at  once.  Such 
cases  play  an  important  part  in  diagnosis. 

The  most  important  malformations  are  described  in  the  divisions 
devoted  to  the  different  organs  or  tracts  of  the  child's  body. 

II.     TRAUMATIC  CONDITIONS 

CAPUT  SUGCEDANEUM 

This  is  a  lesion  of  the  scalp,  seen  in  newborn  infants,  and  caused 
by  the  mechanical  conditions  attending  labor,  especially  when  pro- 

FiG.  54 


Caput  succedaneum.     Male,  2  hours  old 

longed.  There  is  an  extravasation  of  serum,  or  blood,  into  the  sub- 
cutaneous tissues  of  the  scalp.  A  swelling  is  seen,  sometimes  on  one 
side,  sometimes  on  both  sides  of  the  cranium.     The  tumor  is  soft 


Cephalhematoma 


185 


and  flabby,  and  does  not  fluctuate.     It  is  at  its  height  at  birth,  and 
always  disappears  spontaneously  in  the  course  of  two  or  three  days. 


CEPHALHEMATOMA 

This  condition  also  is  due  to  an  injury  received  during  birth,  which 
causes  a  rupture  of  the  sub-periosteal  blood-vessels.  The  result 
is  a  hemorrhage  between  the  periosteum  and  the  bones  of  the  cranium, 
which  manifests  itself  as  a  swelling  of  the  scalp.  This  swelling  is 
usually  not  present  immediately  after  birth,  but  appears  in  the  first 
three  or  four  days  of  life.  The  tumor  is  soft  and  fluctuating,  reaches 
a  variable  size,  and  is  usually  situated  over  one  parietal  bone,  rarely 
over  both.  The  tumor  usually  continues  to  increase  in  size  for 
about  a  week,  becoming  more  tense,  and  may  become  so  large  as  to 
cover  the  w^hole  parietal  bone.     After  a  stationary  period,  it  begins 

Fig.  55 


Double  cephalhematoma.     Infant,  4  daj's  old 

to  diminish  very  slowly,  becoming  softer,  and  often  it  does  not  com- 
pletely disappear  until  as  late  as  the  fourth  month.  The  skin  over 
the  tumor  appears  unchanged,  and  there  is  no  tenderness,  nor  other 
signs  of  inflammatory  reaction.  After  the  tumor  has  been  present 
a  few  days,  an  elevated  ridge  presenting  a  bony  edge  can  be  felt  sur- 
rounding the  tumor. 

Cephalhematoma  is  distinguished  from  caput  succedaneum,  in 
that  it  is  not  at  its  height  at  birth,  but  continues  to  increase  in  size, 
is  fluctuating,  becomes  more  tense,  and  does  not  disappear  so  rapidly. 
It  is  distinguished  from  abscess  of  the  scalp  by  the  absence  of  signs 
of  inflammation.     In  some  cases,  a  cephalhematoma  becomes  con- 


-186  Diseases  of  the  Newborn 

verted  into  an  abscess  through  infection.  In  case  of  doubt,  the 
diagnosis  can  be  settled  by  aspirating  the  contents  of  the  tumor  with 
a  hypodermic  needle  under  the  strictest  aseptic  precautions. 

Cephalhematoma  disappears  spontaneously,  and  requires  no  treat- 
ment other  than  protection  from  external  injury.  When  infected, 
the  treatment  is  that  of  an  abscess. 

HEMATOMA  OF  THE  STERNO-CLEIDO-MASTOID  MUSCLE 

This  condition  also  is  a  traumatic  birth  injury.  Either  from  the 
violence  of  the  expulsive  efforts  of  the  uterus,  or  from  too  great  vio- 
lence on  the  part  of  the  obstetrician,  the  sterno-cleido-mastoid  muscle 
is  torn  in  such  a  way  that  there  occurs  a  hemorrhage  into  its  sheath. 
Soon  after  birth  it  is  noticed  that  the  infant  holds  its  head  to  one  side, 
and  when  the  cause  of  the  torticollis  is  sought,  one  sterno-cleido- 
mastoid  muscle  is  found  contracted,  and  along  the  tense  muscle  a 
small  tumor  is  felt.  Sometimes,  especially  in  infants  with  fat  necks, 
the  tumor  is  difficult  or  impossible  to  feel.  It  is  soft  at  first,  and 
tender  to  the  touch;  later  it  becomes  smaller  and  harder.  Efforts 
to  straighten  the  neck  cause  crying. 

The  tumor  disappears  spontaneously,  but  the  torticolHs  is  apt  to 
persist.  It  is  probable  that  most  cases  of  torticollis  in  young  infants 
are  due  to  this  cause. 

No  treatment  should  be  employed  until  after  all  pain  and  tender- 
ness have  disappeared,  when  massage,  and  gentle  manipulations 
designed  to  stretch  the  shortened  muscle  should  be  begun.  If  these 
measures  fail,  the  child  should  be  referred  to  the  orthopedic  surgeon, 
for  treatment  by  apparatus  or  operation. 

INTRACRANIAL  HEMORRHAGE 

ETIOLOGY. — The  commonest  cause  of  the  intracranial  hemor- 
rhage seen  in  newborn  infants  is  trauma,  the  injury  being  due  to  the 
violence  attending  parturition.  Hemorrhage  is  seen  following  both 
operative  and  normal  labor.  Everything  which  increases  or  prolongs 
pressure  upon  the  head  during  labor  may  be  a  predisposing  cause. 
Such  conditions  as  difficult  or  prolonged  labor,  precipitate  labor, 
di£&culty  in  extracting  the  head  in  breech  presentations,  and  difficult 
instrumental  deliveries,  may  act  as  causes.  Occasionally  intra- 
cranial hemorrhage  is  seen  as  a  manifestation  of  hemorrhagic  disease 
of  the  newborn.  Rare  cases  may  be  associated  with  syphilis,  or  infec- 
tion of  the  newborn. 

PATHOLOGICAL  ANATOMY.— The  hemorrhages  may  occur 
over  the  cortex  of  the  brain,  or  at  the  base.  They  are  found  most 
frequently  beneath  the  tentorium,  usually  over  the  cerebellum,  or 
the  occipital  lobes  of  the  cerebrum,  but  hemorrhages  over  the  cortex 


Intracranial  Hemorrhage   .  187 

are  not  uncommon,  and  even  hemorrhage  into  the  ventricles  has 
been  reported.  The  extent  of  the  hemorrhage  and  amount  of  extra- 
vasated  blood  are  very  variable.  There  may  be  a  single  large  clot, 
or  diffuse  hemorrhage.  The  lesion  may  be  confined  to  one  hemis- 
phere, or  extend  over  both.  The  extravasation  may  be  beneath  the 
pia  mater,  or  in  the  arachnoid  space  between  the  pia  and  the  dura. 
The  source  of  the  hemorrhage  is  also  variable.  In  a  large  propor- 
tion of  cases,  lacerations  of  the  tentorium  have  been  found.  The 
blood  may  come  from  a  laceration  of  one  of  the  sinuses  of  the  dura 
from  overlapping  of  the  bones,  but  more  frequently,  when  there  is 
no  laceration  of  the  tentorium,  the  blood  comes  from  one  of  the  large 
veins  empyting  into  the  sinuses,  or  from  the  rupture  of  a  small  vessel 
in  the  pia. 

SYMPTOMS. — In  intracranial  hemorrhage,  one  would  expect  the 
symptoms  to  be  those  either  of  increased  intracranial  pressure,  or 
of  cortical  irritation.  In  certain  cases  such  symptoms  are  present 
to  such  a  well  marked  degree,  that  the  picture  of  a  cerebral  lesion  is 
very  plain.  Such  cases  are  frequently  asphyxiated  at  birth,  and 
are  only  resuscitated  after  considerable  effort.  They  may  show 
cyanosis,  difficult,  shallow,  or  very  irregular  respiration,  bulging 
fontanelle  or  slow  pulse.  They  may  show  twitching  of  the  extremi- 
ties, or  even  convulsions,  especially  in  cases  which  last  several  days. 
There  may  be  spasm  of  the  extremities,  or  paralysis  of  the  face,  op 
of  one  or  more  of  the  limbs,  and  there  may  even  be  a  general  rigidity 
or  opisthotonus.  In  these  cases  the  deep  reflexes  are  increased, 
the  pupils  may  be  dilated,  or  more  commonly,  contracted,  and  there 
may  be  strabismus  or  nystagmus. 

The  localizing  symptoms  of  cortical  irritation  are  more  frequently 
seen  when  the  hemorrhage  is  situated  over  the  cortex.  When  the 
hemorrhage  is  at  the  base,  the  symptoms  are  those  of  increased  pres- 
sure. In  these  pronounced  cases,  showing  symptoms  of  this  kind, 
death  may  occur  within  twenty-four  hours,  and  with  very  large 
hemorrhages,  the  children  are  usually  still-born. 

Nevertheless,  pronounced  cases  giving  these  distinct  symptoms 
of  a  cerebral  lesion,  are  comparatively  less  common  than  those  in 
which  the  symptoms  are  much  vaguer,  and  less  suggestive  either  of 
increased  intracranial  pressure,  or  of  cortical  irritation.  In  such 
types  the  diagnosis  is  equally  important,  but  more  difficult. 

The  symptoms  are  frequently  not  seen  at  birth,  but  develop  at 
some  time  during  the  first  four  days  of  life,  usually  at  about  the 
second  day.  The  commonest  and  most  suggestive  symptom  is  re- 
fusal to  nurse.  The  babies  are  pale,  and  show  either  restlessness, 
or  seem  very  dull  and  stupid,  rousing  with  difficulty.  There  is  often 
at  this  time  a  slight  facial  edema,  which,  when  present,  is  a  sign  of 


188  Diseases  oe  the  Newborn 

great  significance.  The  appearance  of  refusal  to  nurse  in  a  new- 
born baby  should  always  suggest  the  possibiHty  of  intracranial 
hemorrhage,  while  pallor  and  facial  edema  greatly  strengthen  suspi- 
cion. Careful  examination  for  cyanosis,  disturbed  breathing,  tense 
fontanelle,  slow  pulse,  or  signs  of  cortical  irritation  will  often  confirm 
the  suspicion,  but  it  must  be  remembered  that  localizing  nervous 
symptoms  are  frequently  absent. 

DIAGNOSIS. — When  there  are  found  the  symptoms  of  refusal 
to  nurse,  pallor,  and  possibly  facial  edema  in  a  newly  born  baby, 
intracranial  hemorrhage  should  always  be  suspected.  When  in  addi- 
tion are  found  signs  either  of  increased  intracranial  pressure,  or  of 
cortical  irritation,  the  diagnosis  is  confirmed.  In  the  absence  of 
these  confirmatory  signs,  the  condition  should  always  be  suspected. 
In  doubtful  cases,  lumbar  puncture  should  be  performed.  If  the 
fluid  obtained  is  bloody,  the  diagnosis  of  intracranial  hemorrhage  is 
verified,  provided  that  the  operator  has  performed  the  puncture 
carefully,  and  is  sure  he  has  not  wounded  a  local  blood-vessel.  If 
the  fluid  is  clear,  intracranial  hemorrhage  is  not  excluded,  as  only  in 
cases  where  the  hemorrhage  is  below  the  tentorium,  will  the  fluid 
be  blood  stained.  In  a  case  which  remains  doubtful  after  a  negative 
lumbar  puncture,  confirmation  of  the  diagnosis  may  be  obtained 
by  aspiration  of  the  subdural  space,  as  advocated  by  Henschen.  The 
technic  is  simple.  The  aspiration  is  made  through  a  fontanelle  or 
suture,  care  being  taken  not  to  wound  the  dural  sinuses.  The  most 
favorable  point  is  at  the  lateral  angle  of  the  anterior  fontanelle.  The 
needle  is  entered  in  a  direction  almost  parallel  with  the  surface  of 
the  skull,  and  if  blood  is  not  imxmediately  obtained,  may  be  carefully 
swept  in  various  directions.  The  middle  hne  must  not  be  crossed 
on  account  of  the  falx.  If  blood  is  found,  as  much  may  be  removed 
as  will  flow  through  the  needle. 

PROGNOSIS. — The  prognosis  is  always  serious.  Hemorrhages 
below  the  tentorium  are  probably  always  fatal,  as  are  large  hemor- 
rhages in  any  situation.  Death  may  not  occur  for  four  or  five  days. 
When  the  hemorrhage  is  situated  over  the  convexity  of  the  brain, 
and  is  not  too  large,  the  child  may  survive.  In  such  cases  there  is 
always  serious  damage  to  the  brain,  which  usually  manifests  itself 
later  as  a  cerebral  paralysis.  The  full  extent  of  the  damage  may  not 
become  apparent  for  a  number  of  years. 

It  follows  that  in  cases  in  which  the  signs  of  cortical  irritation  are 
not  marked,  but  in  which  the  signs  are  those  of  intracranial  pressure, 
a  fatal  ending  is  most  certain. 

TREATMENT.— Prophylaxis  is  the  most  important  measure 
available  in  connection  with  so  serious  a  condition  as  intracranial 
hemorrhage.     This    is    mainly    a    matter    for    the    obstetrician.     It 


Obstetrical  Paralysis  189 

must  be  remembered  also  that  slight  and  unavoidable  degrees  of 
trauma  may  be  followed  by  hemorrhage.  The  indications  are  to 
shorten  prolonged  and  tedious  labor,  to  avoid  compressing  the  head 
too  violently  with  the  hand  through  the  perineum,  and  to  avoid 
difficult  high  forceps  operations  whenever  possible. 

Aspiration  of  the  clot  through  the  fontanelle  or  suture  will  some- 
times give  relief  of  symptoms.  If,  when  this  procedure  is  under- 
taken for  diagnosis,  a  considerable  amount  of  blood  can  be  withdrawn, 
it  may  be  wise  to  wait  before  trying  anything  further.  If  little  or 
no  blood  is  obtained,  the  only  treatment  is  by  operation. 

The  operative  treatment  of  intracranial  hemorrhage  of  the  new- 
born consists  of  craniotomy  and  washing  out  of  the  clot.  The  opera- 
tive risk  is  necessarily  great,  but  a  certain  number  of  cases  have 
recovered.  Out  of  seventeen  cases  thus  treated  prior  to  19 14,  seven 
recovered. 

OBSTETRICAL  PARALYSIS 

ETIOLOGY. — Paralysis  in  new-born  babies  is  due  to  trauma 
received  during  parturition.  It  may  be  one  of  the  symptoms  of 
intracranial  hemorrhage,  as  already  described.  The  form  known 
as  obstetrical  paralysis,  or  birth  palsy,  is  caused  by  an  injury  to  the 
peripheral  nerves.  Two  types  of  paralysis  are  seen,  one  involving 
the  muscles  of  the  face,  the  other  involving  the  muscles  of  the  shoulder 
and  upper  arm.  In  the  facial  type,  the  injury  is  usually  due  to  the 
use  of  forceps,  which  press  upon  the  facial  nerve,  either  near  the 
point  of  exit  from  the  stylo-mastoid  foramen,  or  where  it  crosses 
the  ramus  of  the  jaw.  While  pressure  from  forceps  is  the  usual  cause, 
some  cases  have  been  seen  in  which  the  forceps  were  not  used.  In 
these  cases,  it  is  beHeved  that  the  injury  is  received  from  pressure 
following  long  arrest  of  the  head  at  some  point  in  its  passage  through 
the  pelvis. 

In  the  upper  arm  type,  the  injury  received  during  labor  may  be 
caused  in  a  variety  of  ways.  It  is  seen  more  commonly  after  artificial 
labor,  but  may  occur  when  labor  has  terminated  naturally.  In 
vertex  presentations,  it  may  be  caused  by  pressure  from  a  forcep's 
blade  which  extends  down  to  the  neck,  by  traction  upon  the  head 
while  it  is  in  a  rotated  position,  or  by  traction  with  the  obstetrician's 
finger  in  the  axilla.  The  injury  is  much  more  frequent  in  breech 
presentations,  in  which  it  may  be  produced  by  traction  upon  the 
shoulder  in  delivering  the  head,  or  by  pulling  or  twisting  the  arm, 
especially  in  bringing  down  the  arms  when  they  are  above  the  head. 

PATHOLOGICAL  ANATOMY.— In  facial  birth  palsy  the  injury 
is  usually  comparatively  slight,  and  consists  of  exudation  produced 
within  the  sheath  of  the  nerve  bundle  by  pressure.  In  the  upper 
arm  type,  often  known  as  Erb's  Paralysis,   the  injury  affects  the 


190 


Diseases  of  the  Newborn 


nerves  which  form  the  brachial  plexus,  the  nerve  trunks  involved 
-being  usually  the  fifth  and  sixth,  and  sometimes  the  seventh  cervical 
nerves.  In  the  severer  cases,  the  stretching  may  result  in  the  rupture 
of  the  plexus,  or  in  hemorrhage  about  the  plexus.  In  milder  cases 
there  is  hemorrhage  within  the  connective  tissue  sheath  of  the  cord 
of  the  plexus,  with  a  resulting  fusiform  fibrous  swelling.  In  the 
mildest  cases  the  lesion  is  simply  exudation  within  the  sheath  from 
stretching  of  or  pressing  upon  the  nerve  bundle.  The  muscles  most 
commonly  affected  are  the  deltoid,  supra-  and  infra-spinatus,  brachialis 
anticus,  biceps,  supinator  longus,  and  probably  also  the  supinator 

brevis. 

Fig.  56 


Showing  characteristic  position  of  the  arm  in  obstetrical  paralysis  in  a  girl  of  20  months 

SYMPTOMS.— Facial  paralysis  and  severe  upper  arm  paralysis 
are  usually  noticed  on  the  first  or  second  day.  Mild  upper  arm  par- 
alysis may  not  be  noticed  for  a  week.  Facial  paralysis  is  recognized 
by  lack  of  symmetry  in  the  two  sides  of  the  face.  This  is  not  very 
apparent  when  the  child  is  in  repose,  but  it  can  usually  be  noticed 
that  the  eye  on  the  affected  side  remains  open.     When  the  baby 


Obstetrical  Paralysis  191 

cries,  the  whole  side  of  the  face  is  seen  to  be  affected,  the  paralyzed 
side  appearing  smooth  and  full,  while  the  mouth  is  drawn  toward  the 
sound  side.  Nursing  is  not  interfered  with,  as  the  lips  are  Httle 
used  in  sucking,  and  the  tongue  is  not  involved. 

In  Erb's  Paralysis,  the  arm  hangs  limp  and  motionless,  close  to 
the  side;  the  humerus  is  rotated  inward,  and  the  forearm  is  pronated 
so  that  the  palm  looks  outward.  It  is  notable  that  the  movements 
of  the  wrist  and  hand  are  not  affected,  nor  is  the  triceps,  so  that  the 
forearm  can  be  extended,  but  cannot  be  flexed.  The  reaction  of 
degeneration  is  present  in  the  severer  cases.  Atrophy  usually  begins 
after,  a  few  weeks,  but  the  muscles  are  comparatively  so  small,  and 
so  covered  with  fat,  that  it  is  usually  not  perceptible  until  paralysis 
has  persisted  for  one  or  two- years. 

DIAGNOSIS. — Facial  birth  paralysis  has  to  be  distinguished 
only  from  a  facial  paralysis  of  central  origin.  It  is  extremely  rare 
that  facial  paralysis  is  the  sole  manifestation  of  intracranial  hemor- 
rhage, and  it  can  usually  be  easily  excluded  by  the  absence  of  signs 
of  intracranial  pressure  or  of  cortical  irritation.  Moreover,  in  facial 
paralysis  of  central  origin  the  upper  segment  of  the  facial  nerve  is 
not  affected,  there  is  no  paralysis  of  the  orbicularis  palpebrarum,  and 
consequently  the  eye  can  be  closed. 

The  upper  arm  type  of  obstetrical  paralysis  is  also  easily  recog- 
nized. Here  again,  in  a  paralysis  of  central  origin,  it  is  extremely 
rare  for  the  arm  alone  to  be  affected.  The  characteristic  grouping 
of  the  muscles  affected  in  obstetrical  paralysis,  together  with  the 
absence  of  the  signs  of  intracranial  pressure  or  irritation,  usually 
make  the  diagnosis  sufficiently  clear.  The  reaction  of  degeneration, 
when  present,  is  further  proof  of  the  peripheral  origin  of  the  paralysis. 

Erb's  Paralysis,  however,  has  at  times  to  be  carefully  distinguished 
from  surgical  injuries  received  during  birth,  such  as  fractures,  dislo- 
cations, or  separation  of  an  epiphysis  in  the  shoulder.  Careful  ex- 
amination, especially  for  tenderness,  will  exclude  these  conditions. 

PROGNOSIS. — The  prognosis  of  the  facial  type  of  birth  palsy 
is  good.  Only  in  cases  very  rare  and  very  severe,  may  the  paralysis 
be  permanent,  or  even  last  for  several  months.  In  the  majority  of 
cases  it  disappears  without  treatment  in  about  two  weeks. 

The  prognosis  of  the  upper  arm  type  is  very  variable,  depending 
on  the  extent  and  character  of  the  injury  to  the  nerve  plexus,  and 
upon  the  treatment.  As  time  passes,  partial  recovery  is  alwa3''s  seen, 
even  with  untreated  cases.  In  some  cases  spontaneous  recovery  is 
seen  in  the  course  of  a  few  months.  Even  when  recovery  does 
not  occur  in  untreated  cases,  the  flexion  of  the  forearm  at  the  elbow 
and  the  abduction  of  the  arm  from  the  trunk  are  usually  regained. 
Pronation  of  the  forearm,  and  external  rotation  of  the  humerus  are 


192 


Diseases  of  the  Newborn 


the  movements  which  remain  most  persistently  poor.  With  treatment 
begun  at  the  proper  time,  recovery  usually  occurs  after  a  time  vary- 
ing from  a  few  months  to  one  or  two  years. 

In  the  majority  of  untreated  cases,  and  in  a  few  of  the  severer 
cases  even  under  proper  treatment,  the  paralysis  persists,  to  a  vary- 
ing degree.     Atrophy  of  the  muscles  becomes  noticeable,  especially 


Fig 


Obstetrical  paralysis 

in  the  deltoid,  the  shoulder  droops,  and  there  is  a  lack  of  development 
of  the  bones  of  the  shoulder  girdle  as  a  result  of  disuse.  The  arm 
appears  shrunken,  and  shorter  than  on  the  sound  side.  Contractions 
in  the  muscles  of  the  forearm  and  hand  may  eventually  develop. 
Finally,  in  the  worst  cases,  fortunately  rare,  there  is  loss  of  response 
to  either  the  galvanic  or  faradic  current,  and  the  arm  remains  com- 
paratively useless. 

It  is  a  noticeable  feature  in  this  type  of  paralysis,  that  even  in  severe 
cases,   atrophy   takes  place   comparatively   slowly.     In   comparison 


Obstetrical  Paralysis  193 

with  similar  paralysis  due  to  poliomyelitis,  there  is,  as  pointed  out 
by  Thomas,  a  notable  lack  of  flaccidity,  hypotonia,  and  atrophy  in 
the  affected  muscles.  This  fact  is  of  value  in  prognosis,  as  showing 
that  considerable  good  may  be  expected  in  cases  which  have  gone 
for  a  long  time  untreated,  if  proper  therapeutic  measures  are  instituted. 
The  presence  or  absence  of  the  reaction  of  degeneration  is  of  some 
value  in  prognosis.  Its  presence  points  toward  a  severer  type  of 
lesion. 

TREATMENT. — The  earlier  treatment  of  these  cases  is  by  mas- 
sage, electrical  stimulation,  and  educational  gymnastics.  Treat- 
ment should  be  begun  at  the  end  of  the  first  month,  and  should  be 
continued  regularly  and  systematically  for  many  months. 

Electrical  stimulation  has  always  been  a  conventional  part  of  the 
treatment  of  these  cases.  I  have  never  been  able  to  convince  myself 
that  it  is  of  very  great  value.  It  has  been  given  up  at  the  Children's 
Hospital,  partly  because  it  is  much  less  effective  than  the  other  meas- 
ures, and  partly  because  the  muscles  which  need  exercise  the  most, 
namely,   the  spinati,   cannot  be  reached  by  electrical  stimulation. 

The  treatment  by  massage  and  educational  gymnastics,  as  prac- 
tised by  Dr.  Thomas  of  the  Children's  Hospital,  seems  to  me  to  be 
most  satisfactory,  and  I  have  seen  a  number  of  strikingly  favorable 
results  from  its  use.  As  described  by  Thomas,  the  treatment  is 
carried  out  as  follows,  consisting  of  three  parts: 

1.  Passive  movements  of  the  joints,  shoulder,  elbow,  wrist  and 
fingers,  best  done  by  some  one  who  knows  the  anatomical  possibil- 
ities and  limitations  of  these  joint  movements.  These  movements 
need  to  be  continued  until  the  arm  has  entirely  recovered. 

2.  Massage  of  the  gentle  kneading  form,  to  stimulate  growth, 
which  may  be  discontinued  when  the  arm  keeps  up  in  growth  with  the 
unaffected  one. 

3.  Exercises,  to  induce  the  child  to  use  the  arm  voluntarily,  which 
vary  with  the  age  of  the  child. 


13 


III.     NON-TRAUMATIC  MECHANICAL 
DISTURBANCES 

This  group  represents  certain  lesions  of  a  mechanical  nature,  of 
which  the  anatomy  and  mechanism  is  understood,  but  of  which  the 
ultimate  etiology  is  unknown.  The  most  common  conditions  of 
this  group  are  the  various  forms  of  hernia  seen  in  newborn  babies. 
Both  inguinal  and  femoral  hernia  are  sometimes  seen  at  birth,  but 
are  not  strictly  to  be  classed  as  diseases  of  the  newborn.  There  are 
other  mechanical  conditions  which,  while  they  may  be  seen  at  birth, 
occur  more  frequently  at  a  later  age;  examples  of  such  conditions 
are  volvulus  and  intussusception. 

UMBILICAL  HERNIA 

This  is  the  only  common  mechanical  condition  strictly  to  be  classi- 
fied among  the  diseases  of  the  newborn,  and  even  this  often  does  not 


Fig.  cS 


Large  umbilical  hernia.     Infant  5  months  old 

appear  for  a  considerable  time  after  birth,  its  development  being 
favored  by  poor  nutrition.  When  it  appears  shortly  after  birth, 
it  is  most  frequently  seen  in  premature,  or  congenitally  weak  infants. 
There  is  a  soft  tumor  at  the  umbilicus,  caused  by  a  protrusion  of 
a  small  part  of  the  abdominal  contents  through  the  umbiKcal  ring, 
which  is  found  dilated.  The  tumor  varies  much  in  size,  the  usual 
hernia  being  about  half  an  inch  in  diameter,  but  occasionally  it  may 
be  very  large.  It  rarely  becomes  strangulated,  and  is  usually  not 
serious. 


Umbilical  Hernia 


195 


TREATMENT. — In  the  first  two  or  three  months,  after  the  cord 
has  separated,  a  firm  pad  should  be  placed  over  the  navel,  kept  in 
place  by  a  rather  snug  abdominal  band.  In  cases  coming  under 
observation  at  a  later  period,  the  pad  and  band  are  not  enough,  and 
adhesive  plaster  should  be  used.  A  coin  or  button  covered  with  kid 
may  be  placed  over  the  umbilicus,  and  kept  in  place  by  strips  of 
adhesive  plaster.  I  prefer  the  procedure  which  we  use  at  the  Infants' 
Hospital,  to  the  use  of  a  coin  or  button.  After  the  parts  are  well 
powdered,  and  the  hernia  is  reduced,  the  skin  of  the  abdomen  on  each 
side  is  picked  up  between  the  finger  and  thumb  of  each  hand,  in  such 
a  manner  as  to  make  two  vertical  folds.  These  folds  are  then  brought 
over  to  the  middle  line,  so  that  they  touch  one  another  over  the  center 
of  the  navel.     They  may  then  be  held  in  place  by  the  finger  and 


Fig.  sq 


Adhesive  strap  for  umbilical  hernia 


thumb  of  one  hand,  while  the  other  hand  applies  snugly  a  broad 
strip  of  adhesive  plaster.  This  holds  the  two  folds  of  skin  together 
over  the  navel  in  such  a  way  that  they  form  the  pad  which  retains 
the  hernia.  This  plaster  may  be  changed  every  few  days,  and  must 
be  worn  for  months. 

Very  large  herniae,  or  persistent  herniae  can  only  be  cured  by 
surgical  operation.     Operation,  however,  is  seldom  necessary. 


196  Diseases  of  the  Newborn 

There  is  a  rare  condition  of  hernia  into  the  umbilical  cord,  which 
is  entirely  different  from  the  commoner  umbilical  hernia.  This  is 
a  malformation,  due  to  some  fetal  defect.  It  varies  in  size  from  a 
comparatively  small  tumor  to  complete  eventration  in  which  most 
of  the  abdominal  organs  are  in  the  sack  and  outside  the  body.  Such 
severe  cases,  with  complete  eventration,  are  fatal.  Milder  cases, 
even  though  the  tumor  is  quite  large  and  contains  a  number  of  coils 
of  intestine,  may  be  cured  by  surgical  treatment. 

PROLAPSE  OF  MECKEL'S  DIVERTICULUM 

This  is  a  condition  which  produces  a  tumor  at  the  umbiUcus  in 
newborn  babies,  and  with  it  there  is  usually  an  umbiHcal  fistula. 
The  tumor  is  formed  by  a  prolapse  of  the  mucous  membrane  of 
Meckel's  Diverticulum.  Normally  the  omphalo-mesenteric  duct 
closes  completely  during  fetal  life.  The  duct  may  however  remain 
patent  to  a  varying  extent,  the  most  common  finding  in  such  cases 
being  a  blind  pouch  a  few  inches  in  length  given  off  from  the  lower 
part  of  the  ileum.  In  rare  cases  it  may  be  patent  at  birth  throughout 
its  entire  extent,  and  a  prolapse  of  its  mucous  membrane  produces 
a  tumor  at  the  umbiHcus  with  a  fistula  at  its  summit. 

These  tumors  are  usually  small,  not  larger  than  a  common  marble, 
but  may  be  much  larger.  They  are  smooth,  of  a  pink  color,  and 
cannot  be  reduced.  A  mucous  discharge  oozes  from  their  surface, 
and  a  slight  fecal  discharge  comes  from  the  fistula.  Tumors  are 
sometimes  seen  without  a  fecal  fistula,  but  microscopic  examination 
shows  that  their  covering  is  the  same  as  in  cases  with  a  fistula,  the 
structure  being  that  of  the  intestinal  mucosa.  In  other  cases,  the 
fecal  fistula  may  exist  without  a  tumor.  These  fistulae  may  exist 
for  months  or  years,  may  close  spontaneously,  or  be  closed  by  opera- 
tion. The  small  tumors  most  often  seen  are  easily  cured  by  Hgation. 
The  rare  large  tumors  are  usually  associated  with  serious  malforma- 
tion of  the  intestines. 


IV.     NEW  GROWTHS 

While  various  forms  of  new  growths  may  be  present  at  birth,  their 
occurrence  is  so  rare,  that   they  constitute  pathological   curiosities. 


UMBILICAL  GRANULOMA 

After  the  cord  has  fallen  off,  there  is  sometimes  seen  at  the  umbili- 
cus a  reddish,  moist,  secreting  mass  of  granulations.  This  condi- 
tion is  usually  due  to  improper  care  of  the  stump  of  the  cord,  in  which 
case  a  mild  infection  may  play  an  etiologic  role.  The  condition  is 
commoner  in  hospital  out-patient  than  in  private  practice.  The 
usual  story  is  that  the  navel  will  not  heal.  The  tumor  varies  in  size 
from  the  head  of  a  pin  to  a  pea.  The  discharge  is  irritating,  so  that 
the  skin  around  the  umbilicus  may  be  eczematous.  A  neglected 
overgrown  granuloma  becomes  a  polyp.  These  polyps  are  more 
vascular  than  the  simple  granuloma,  and  have  a  pedicle. 

TREATMENT. — The  simple  granuloma  is  best  treated  by  one 
or  more  applications  of  a  50  per  cent,  nitrate  of  silver  solution,  and 
by  keeping  the  part  thoroughly  powdered  with  some  absorbent 
powder.  Polyps  should  not  be  treated  by  cutting  the  pedicle  and 
applying  nitrate  of  silver,  as  hemorrhage  is  sometimes  severe.  The 
pedicle  should  be  ligated,  and  the  polyp,  kept  freely  powdered,  will 
dry  up  and  fall  off. 

NAEVUS 

This  is  a  congenital  new-formation  of  tissue  in  the  skin;  the  new- 
formed  tissue  may  be  pigmentary  or  vascular. 

ETIOLOGY.— The  etiology  of  naevus,  as  of  new  growths  in  gen- 
eral, is  obscure.  None  of  the  theories  as  to  the  cause  of  naevus  ad- 
vanced at  various  times,  have  been  supported  by  any  proof.  One 
theory  is  that  birth  marks  are  produced  by  intrauterine  pressure; 
the  only  evidence  in  support  of  this  theory  is  the  frequent  occurrence 
of  birth  marks  at  the  back  of  the  head  or  neck,  and  on  the  face.  Vir- 
chow  called  attention  to  the  frequency  of  naevi  at  embryonic  fissures 
of  the  skin,  where  slight  irritation  might  easily  give  rise  to  abnormal 
vascular  activity. 

PATHOLOGICAL  ANATOMY.— Various  forms  of  pigmented 
moles  are  seen  at  times,  of  various  shades  of  brown  or  black.  Some 
are  smooth,  some  rough  and  warty,  some  hairy. 


198 


Diseases  op  the  Newborn 


The  commoner  forms  of  naevi  are  vascular,  and  include  the  well- 
known  so-called  birth  marks.  They  vary  in  histology,  in  size,  and 
in  appearance,  from  the  small  capillary  angioma,  to  the  large,  dis- 
figuring "port  wine"  stain.  The  appearances  vary  with  the  number, 
and  degree  of  dilatation  of  the  new-formed  vessels.  True  vascular 
naevi  become  pale  on  pressure. 


Fig.  6o 


Naevus  ot  lace  and  neck  in  an  infant  4  months  old 


TREATMENT. — The  smaller  pigmented  moles  are  best  treated 
by  excision.  It  must  be  remembered  that  metastasis  and  general 
sarcomatosis  have  occasionally  followed  mechanical  interference 
with  certain  forms  of  moles.  The  same  thing,  however,  occurs  with 
equal  if  not  greater  frequency  when  there  is  no  attempt  at  excision, 
and  it  is  probable  that  children  are  not  so  liable  to  metastasis  as 
adults.  Smooth  pigmented  moles  should  be  left  alone,  if  not  in  a 
disfiguring  situation.  The  warty  variety,  in  my  opinion,  should 
be  excised. 

Large  hairy  moles,  and  vascular  naevi,  are  treated  by  electrolysis, 
or  multiple  puncture.  Some  small  capillary  naevi  will  disappear 
under  the  pressure  produced  by  frequent  apphcations  of  collodion 
(Kerley). 

The  best  results  in  the  treatment  of  vascular  naevi,  have  been 
obtained  by  freezing  wdth  liquid  air  or  carbon  dioxide  snow. 


V.     FUNCTIONAL  DISTURBANCES 

CONGENITAL  PULMONARY  ATELECTASIS 

This  condition  is  one  in  which  the  whole  or  parts  of  the  lung  re- 
main in  a  fetal  condition,  air  not  entering  the  alveoli. 

ETIOLOGY. — It  is  usually  stated  in  textbooks  that  atelectasis  is 
closely  associated  with  Asphyxia  Neonatorum,  this  statement  being 
based  on  the  fact  that  infants  born  dead,  or  dying  as  the  result  of 
asphyxia  show  a  complete  or  partial  condition  of  atelectasis  post- 
mortem, and  that  most  cases  in  which  infants  die  in  the  first  few  days 
of  life,  and  in  whom  the  lesions  of  atelectasis  are  found  post-mortem, 
have  shown  symptoms  of  asphyxia  at  birth.  I  believe,  however,  that 
the  connection  between  asphyxia  and  atelectasis  is  not  so  close  as 
is  generally  supposed.  It  is  a  well-known  fact  that -the  expansion 
of  the  lung  is  not  normally  completed  immediately  after  birth,  but 
is  a  gradual  process,  occupying  a  number  of  days  before  complete 
expansion  of  the  lung  is  attained.  It  follows  that  a  certain  amount 
of  atelectasis  would  always  be  found  post-mortem  in  infants  dying 
in  the  first  few  days  of  life,  whether  they  die  from  asphyxia,  or  from 
any  other  cause.  Further,  most  of  the  conclusions  upon  the  cause 
of  atelectasis  are  based  on  post-mortem  examinations  of  infants  dying 
in  the  first  few  days  of  hfe,  and  in  these  cases  asphyxia  may  well  have 
been  the  cause  of  death,  or  it  may  have  been  a  symptom  of  a  feeble 
vitality  which  was  the  cause  of  death.  In  my  experience,  infants 
who  survive  the  early  days,  and  later  show  the  lesions  or  signs  of 
atelectasis,  do  not  give  a  history  of  asphyxia  at  birth. 

Atelectasis  becomes  a  pathological  condition  when  it  persists 
beyond  the  early  days  of  life.  The  cause  is  congenital  weakness  of 
any  kind,  such  as  is  seen  in  premature  infants,  in  congenitally  weak 
or  malnourished  infants,  and  in  infants  suffering  from  congenital 
syphilis  or  cerebral  hemorrhage.  Anything  which  impairs  the  vital- 
ity of  the  newborn  infant,  causes  weakened  respiratory  efforts,  and 
asphyxia  undoubtedly  may  be  numbered  among  the  causes  of  such 
weakness.  In  addition  to  weakened  respiratory  efforts,  in  feeble 
infants  there  is  weakened  heart  action,  leading  to  pulmonary  con- 
gestion or  edema,  and  the  two  together  form  a  vicious  circle  of 
which  atelectasis  is  the  result. 

Asphyxia  is  usually  due  to  some  intrauterine  condition  interfering 
with  the  placental  circulation,  such  as  prolonged  labor,  the  use  of 
ergot  in  the  second  stage,  pressure  on  the  cord,  winding  of  the  cord 
about  the  neck,  or  early  separation  of  the  placenta.     It  is  a  condition 


200  Diseases  of  the  Newborn 

rarely  seen  by  the  pediatrist,  its  diagnosis  and  treatment  falling  more 
properly  to  the  obstetrician,  and  it  is  so  adequately  described  in  text- 
books on  obstetrics,  that  it  will  not  be  described  here. 

PATHOLOGICAL  ANATOMY.— In  infants  who  are  born  dead 
from  asphyxia,  atelectasis  is  complete,  the  lung  showing  a  fetal 
condition.  There  are  no  alveoli,  the  tissue  consisting  of  closely  packed 
epithelioid  cells  and  blood-vessels,  and  is  recognizable  as  lung  tissue 
only  by  the  bronchioles  with  their  characteristic  epithelium.  In 
infants  who  breathe  at  birth,  but  who  die  from  asphyxia  or  congenital 
weakness  at  any  time  in  the  first  few  days  of  life,  the  amount  of  un- 


FlG. 


Complete  congenital  atelectasis  of  the  left  lung.     Hypertrophy  of  the  heart 

expanded  lung  is  very  variable,  varying  to  a  certain  extent  with  the 
length  of  time  the  child  survives.  At  the  borders  of  completely  col- 
lapsed areas,  are  areas  where  some  air-containing  alveoli  are  seen,  there 
being  a  gradual  transition  to  the  areas  where  the  lung  is  completely 
inflated.  Often  in  the  most  collapsed  areas  are  found  some  air  spaces. 
In  addition  to  the  fetal  condition,  there  is  frequently  edema 
filling  the  expanded  alveoH  of  the  atelectatic  areas.  The  blood- 
vessels are  congested. 


Congenital  Pulmonary  Atelectasis  201 

In  children  who  survive  the  early  days  of  life,  there  is  httle  evi- 
dence available  as  to  the  pathological  anatomy.  It  is  probable  that 
there  is  a  persistence  of  the  fetal  condition  in  more  or  less  extensive 
areas  of  the  lung. 

The  portions  of  the  lung  most  frequently  involved  in  congenital 
atelectasis  are  the  paravertebral  and  central  portions,  particularly 
the  area  just  behind  the  hilus.  The  outer  portions  and  borders 
expand  better.  The  best  expanded  portions  are  usually  the  anterior 
borders  of  the  upper  lobes.  The  left  lung  is  more  frequently  and  more 
fully  involved  than  the  right. 

SYMPTOMS.— In  the  beginning,  at  birth,  the  symptoms  of 
atelectasis  are  the  same  as  those  of  asphyxia.  In  other  words,  a 
certain  amount  of  asphyxia  is  frequently  present  at  birth  in  cases 
of  atelectasis.  During  the  first  few  days  of  life  the  symptoms  are 
those  of  general  feebleness  and  low  vitahty.  The  infants  are  somno- 
lent, do  not  cry  strongly,  and  do  not  take  their  nourishment  well. 
Their  faces  are  pale  and  expressionless.  In  the  severer  cases,  the 
respiration  is  notably  defective,  being  irregular  and  shallow,  with 
occasional  long  pauses  followed  by  a  single  deep  gasping  inspiration, 
after  which  shallow  irregular  breathing  is  resumed.  During  these 
deep  inspirations,  which  may  be  brought  about  artificially  by  slapping 
the  child  with  the  hand,  or  by  applying  cool  water  to  the  chest, 
crepitant  rales  may  frequently  be  heard  in  various  parts  of  the  lungs. 
Sometimes  it  may  be  noted  that  the  respiratory  movements  are  not 
symmetrical,  one  side  of  the  chest  moving  more  than  the  other. 

In  the  majority  of  cases  of  atelectasis  physical  signs  on  ausculta- 
tion and  percussion  cannot  be  found.  In  rare  cases  there  is  consid- 
erable dullness  and  diminished  breathing  over  a  varying  area  of 
the  lung. 

The  further  course  of  these  cases  is  very  striking.  The  children 
do  not  thrive,  but  seem  feeble,  gaining  very  slowly,  or  not  at  all  in 
weight,  with  a  tendency  toward  cyanosis,  cold  extremities,  and  sub- 
normal temperature.  Their  cry  remains  notably  weak.  If  they 
survive  the  early  weeks,  they  remain  smiall  and  delicate.  A  child 
with  very  slight  atelectasis  may  eventually  develop  normally,  but 
in  these  cases,  the  atelectasis  is  usually  not  to  be  recognized.  Occa- 
sionally a  child  survives  with  an  extensive  atelectasis.  Such  children 
remain  very  much  under-sized  in  both  height  and  weight.  I  know 
of  one  such  child,  who  has  reached  the  age  of  twelve  years.  One 
lung  is  still  almost  wholly  collapsed,  showing  dulness  and  diminished 
breathing  over  the  greater  part  of  the  left  chest.  The  chest  wall 
has  sunk  in  over  the  collapsed  lung,  causing  a  marked  deformity  of  the 
chest.  This  patient  was  very  delicate  during  infancy  and  early  child- 
hood, but  is  now  strong  and  healthy,  though  very  much  undersized. 


202  Diseases  of  the  Newborn 

DIAGNOSIS. — Any  child  who  dies  in  the  first  days  of  life  will 
show  some  atelectasis  post-mortem.  In  children  who  survive  the 
first  days,  the  diagnosis  is  difficult.  If  asphyxia  has  been  present 
at  birth,  and  if  the  children  show  impaired  vitality  with  notable 
disturbance  of  the  respiration,  atelectasis  may  be  suspected.  It 
cannot  be  diagnosed  with  certainty  except  in  those  rare  cases  which 
show  abnormalities  to  auscultation  and  percussion.  In  a  certain 
number  of  cases  not  showing  physical  signs,  the  condition  will  be 
revealed  by  roentgen  ray  examination. 

PROGNOSIS. — Slight  degrees  of  pulmonary  atelectasis  are  prob- 
ably compatible  with  normal  development.  Such  cases,  however, 
are  seldom  recognized.  In  the  majority  of  cases  the  children  are 
very  feeble,  and  in  babies  born  with  such  low  vitality,  the  mortaHty 
is  very  high.  A  certain  number  die  in  the  first  days  of  life;  others 
may  survive  for  several  weeks.  A  few  cases,  even  those  in  which 
atelectasis  has  been  clearly  recognized,  survive  the  early  weeks.  They 
remain  puny,  small,  and  delicate,  and  are  difficult  to  rear.  A  few 
survive,  but  even  these  show  backward  growth  and  development 

TREATMENT.— At  birth,  the  physician  should  make  sure  that 
the  child  cries  strongly,  and  should  see  to  it  that  this  cry  is  repeated 
every  day.  The  various  means  of  resuscitation  employed  in  asphyxia 
neonatorum  is  adequately  described  in  works  on  obstetrics.  Feeble 
infants  in  whom  atelectasis  is  suspected,  should  have  the  treatment 
for  asphyxia  continued.  During  each  twenty-four  hours,  they  should 
be  taken  from  their  cribs  a  number  of  times,  and  thoroughly  aroused, 
and  should  be  made  to  take  a  number  of  deep  inspirations.  This  may 
be  brought  about  in  various  ways.  In  the  milder  cases  shaking  or 
slapping,  or  applying  cool  water  to  the  face  and  chest,  will  suffice. 
In  severer  cases  they  should  be  dipped  alternately  into  warm  and  cold 
baths,  as  is  done  in  asphyxia. 

The  rest  of  the  treatment  is  that  applicable  to  any  premature,  or 
congenitally  feeble  baby.  They  must  be  kept  warm,  often  with 
artificial  heat  in  the  form  of  hot  water  bottles.  Sometimes  their 
temperature  will  remain  subnormal  unless  the  "premature  jacket"  is 
used,  as  described  for  premature  infants.  They  are  often  too  feeble 
to  nurse  the  breast,  yet  breast  milk  is  almost  an  absolute  essential  to 
their  proper  nutrition.  In  such  cases  the  breast  milk  must  be  drawn 
with  a  breast  pump,  and  given  to  the  baby  with  a  medicine  dropper, 
or  better  still,  with  a  Breck  feeder. 

HEMORRHAGIC  DISEASE  OF  THE  NEWBORN 

Hemorrhage  in  the  first  few  days  of  hfe  is  seen  in  connection  with 
a  great  variety  of  recognizable  causes.  The  trauma  of  birth  not 
infrequently  produces  a  lesion  of  the  blood  vessels,  but  in  hemor- 


Hemorrhagic  Disease  of  the  Newborn  203 

rhages  of  simple  traumatic  origin,  there  is  no  tendency  for  the  bleeding 
to  be  either  unduly  prolonged,  or  uncontrollable,  and  the  purely 
traumatic  origin  of  the  hemorrhage  is  usually  plainly  apparent.  The 
recognized  infections  of  the  newborn  are  frequently  attended  by 
hemorrhage.  In  these  cases  also,  the  symptomatic  nature  of  the 
hemorrhage  is  usually  apparent,  and  the  clinical  picture  is  comparable 
with  that  sometimes  seen  in  cases  of  infection  in  later  life,  with  a 
tendency  to  hemorrhage,  such  as  occurs  at  times  in  measles,  smallpox, 
and  malignant  endocarditis.  There  remains  a  class  of  cases  in  which 
the  hemorrhages  are  not  associated  with  any  other  recognizable  pro- 
cess, and  in  which  the  bleeding  does  tend  to  be  both  unduly  prolonged, 
and  uncontrollable.  A  very  few  cases  of  this  character  represent 
manifestations  shortly  after  birth  of  that  particular  congenital  and 
hereditary  hemorrhagic  disease  known  as  hemophilia.  Hemophilia, 
however,  is  a  disease  which  persists  throughout  the  life  of  the  patient, 
and  the  appearance  of  hemorrhage  soon  after  birth  is  not  a  char- 
acteristic manifestation  of  the  disease,  but  only  accidental,  occurring 
in  comparatively  few  cases.  In  these  cases,  if  there  is  traumatic 
injury  sufficient  to  produce  hemorrhage,  the  hemorrhage  attracts 
attention  by  its  persistent  and  uncontrollable  character.  Most  cases 
of  hemophilia  do  not  manifest  themselves  at  birth. 

Finally,  we  have  a  class  of  cases  in  which  prolonged  and  uncon- 
trollable hemorrhages  occur  in  newborn  babies,  and  in  which  the 
disease  is  self -limited,  the  tendency  toward  hemorrhage  ceasing 
permanently  when  recovery  occurs.  These  cases,  in  the  present 
state  of  our  knowledge,  are  grouped  under  the  term  Hemorrhagic 
Disease  of  the  Newborn. 

ETIOLOGY. — The  etiology  of  hemorrhagic  disease  of  the  new- 
born is  one  of  the  obscure  problems  of  medicine.  There  are  two 
principal  possibilities  as  to  the  cause  of  these  hemorrhages.  The 
first  is  that  the  bleeding  is  due  to  some  peculiarity  in  the  tissues  of 
the  newborn  infant.  The  second  is  that  it  is  a  manifestation  of  some 
obscure  infection.  Under  the  first  possibility  the  tissue  peculiarity 
cannot  be  a  permanent  defect,  because  hemorrhagic  disease  of  the 
newborn  is  self-limited,  and  is  thus  distinguished  from  hemophilia, 
in  which  the  probable  cause  is  a  permanent  tissue  defect.  The  defect 
in  hemorrhagic  disease  of  the  newborn,  if  such  a  defect  exists,  must 
be  developmental  in  origin,  a  condition  incidental  to  the  relative 
physiological  incompleteness  of  the  newborn  baby.  Such  a  defective, 
incomplete  condition  of  the  tissues  might  involve  either  the  blood 
itself,  or  the  walls  of  the  vessels. 

Under  the  other  possibility,  in  which  the  hemorrhage  is  attributed 
to  some  obscure  infection,  the  immediate  cause  of  continued  bleeding 
is  also  to  be  sought  in  some  defect  either  of  the  blood  itself,  or  of  the 


204  Diseases  of  the  Newborn 

vessel  walls.  The  only  difference  is  that  under  this  theory,  the  cause 
of  the  defect  is  not  developmental  incompleteness,  but  infection  work- 
ing upon  the  tissues  through  toxins. 

The  disease  is  not  a  very  common  one.  The  majority  of  reports 
show  a  percentage  incidence  of  under  2%.  Townsend's  report  from 
the  Boston  Lying-in  Hospital  showed  32  cases  out  of  5,225  births,  or 
•57%-  Green  and  Swift,  in  a  more  recent  series  from  the  same  hos- 
pital, report  51  cases  out  of  4,455  births,  or  1.14%.  In  Prague,  Ritter 
observed  190  cases  out  of  13,000  births,  or  1.46%.  The  highest  record 
I  have  seen  is  8%  out  of  740  births.  The  disease  is  more  frequent 
in  institutions  than  in  private  practice.  In  Green  and  Swift's  series, 
there  was  a  notable  seasonal  incidence,  the  disease  being  more  frequent 
in  the  six  months  from  November  to  April  inclusive.  IMales  are  only 
very  sKghtly  more  frequently  affected  than  females.  S}^hilis  is  asso- 
ciated with  hemorrhagic  disease  in  only  a  small  proportion  of  cases. 

PATHOLOGICAL  ANATOMY.— There  is  no  constancy  in  the 
lesions  found  post-mortem  in  hemorrhagic  disease  of  the  newborn. 
In  the  majority  of  autopsies  nothing  is  found  except  the  hemorrhages 
in  the  various  situations,  and  the  consequent  anaemia  of  the  organs. 
The  stom.ach  and  intestines  frequently  contain  considerable  blood, 
but  usually  show  no  lesions,  except  areas  of  congestion  or  ecchymosis 
on  the  mucous  membrane.  A  few  cases  have  been  reported  in  which 
ulcers  have  been  found  on  the  gastric  or  intestinal  mucosa.  The 
proportion  of  these  cases  is  small,  and  the  cause  of  the  ulcers  obscure. 
The  changes  found  in  the  blood  have  not  been  uniform,  and  have 
not  been  thoroughly  studied. 

SYMPTOMS. — The  hemorrhage  begins  usually  in  the  first  week 
of  life,  and  very  rarely  occurs  after  the  twelfth  day.  The  majority 
of  the  infants  are  two  or  three  days  old. 

The  hemorrhages  are  usually  multiple.  They  occur  from  a  great 
variety  of  situations,  including  the  intestine,  stomach,  mouth,  nose, 
umbilicus,  skin,  genito-urinary  tract,  eyes,  meninges.  In  Green  and 
Swift's  series,  the  cases  arranged  themselves  in  three  distinct  clinical 
groups.  The  largest  group  is  the  sero-mucous,  in  which  the  bleeding 
comes  from  the  mucous  or  serous  membranes.  In  the  second  largest 
group  the  principal  bleeding  is  from  the  umbilicus.  The  smallest 
group  is  characterized  principally  by  the  formation  of  subcutaneous 
purpuric  patches  or  ecchymoses. 

Table  17 
Classification  of  Green  and  Sunft's  Series 

Clinical  Tj'pe  Cases  Recoveries  Deaths 

Sero-Mucou? 27  13  14 

Umbilical 15  6  9 

Purpuric 9  7  2 

51  26  2^ 


Hemorrhagic  Disease  of  the  Newborn  205 

Usually  nothing  abnormal  is  noted  until  the  hemorrhage  begins. 
In  the  sero-mucous  group,  the  most  frequent  symptom  is  hemorrhage 
from  the  bowel.  The  blood  is  always  dark  colored,  and  usually  thor- 
oughly mixed  with  the  feces.  Clots  are  comparatively  rare.  In 
cases  where  there  is  also  hemorrhage  from  the  stomach,  blood  is  vom- 
ited, usually  not  in  great  abundance.  The  blood  vomited  is  usually 
dark  brown,  rarely  bright  red.  In  other  cases  there  may  be  bleeding 
from  the  mouth,  nose,  or  conjunctiva.  When  there  is  hematuria, 
the  urine  is  blood-stained,  and  sometimes  contains  clots.  Occasionally 
bleeding  from  the  female  genitals  is  severe. 

The  bleeding  from  the  umbilicus  is  apt  to  occur  somewhat  later 
than  the  sero-mucous  bleeding.  It  usually  betrays  itself  first  by  a 
slight  stain  on  the  dressing,  though  occasionally  it  begins  more  pro- 
fusely. Hemorrhage  into  the  skin  is  most  apt  to  appear  in  places 
exposed  to  pressure,  but  many  occur  anywhere. 

The  amount  of  the  hemorrhage  is  very  variable.  Sometimes  there 
is  only  a  continuous  oozing;  at  other  times  larger  amounts  of  blood 
are  lost.  There  is  prostration,  which  is  often  marked  from  the  begin- 
ning, and  there  is  rapid  loss  of  weight.  The  temperature  may  be 
elevated,  or  may  be  normal  or  subnormal.  There  is  frequently 
diarrhea. 

The  hemorrhages  continue  until  death  or  until  recovery  occurs.  In 
the  mild,  favorable  cases  which  recover,  the  duration  is  usually  not 
more  than  one  or  two  days.  In  fatal  cases,  death  usually  occurs  in 
three  days.  Death  may  result  either  from  the  rapid  loss  of  blood,  or 
more  frequently,  from  failure  of  vitahty. 

DIAGNOSIS. — It  is  sometimes  necessary  to  make  sure  that  the 
dark  masses  passed  from  the  bowel  are  blood  and  not  meconium.  In 
such  a  case  one  should  first  examine  the  discharges  microscopically 
for  blood  corpuscles,  and  if  they  are  not  conclusively  found  on  account 
of  their  disorganization,  a  chemical  test  for  hemoglobin  should  be 
made. 

Accidental,  or  traumatic  hemorrhages  are  usually  easily  recog- 
nized, and  are  not  persistent.  When  it  is  estabhshed  that  a  hemor- 
rhagic condition  is  actually  present,  the  causes  to  be  excluded  are  hemo- 
philia, and  symptomatic  hemorrhage  in  infectious  disease  of  the  new- 
born. Hemophilia  is  a  rare  manifestation  at  birth;  males  are  affected 
oftener  than  females  in  the  proportion  of  thirteen  to  one;  there  is 
usually  a  history  of  heredity,  particularly  in  the  maternal  grand- 
father; finally  the  hemorrhage  is  usually  from  one  situation  only. 

In  infectious  disease  of  the  newborn,  there  is  usually  a  persistent 
fever,  and  some  signs  of  infection  on  physical  examination,  such  signs 
being  most  frequently  found  at  the  umbiHcus. 

In  a  few  cases  the  hemorrhage  is  into  some  internal  organ,  and 


206  Diseases  of  the  Newborn 

does  not  appear  externally.     In  such  cases  the  diagnosis  is  so  difficult, 
that  the  disease  usually  escapes  recognition. 

PROGNOSIS.— The  mortality  of  hemorrhagic  disease  of  the  new- 
born is  high.  It  varies  in  the  reports  of  different  observers,  the 
variations  depending  on  the  differences  in  the  severity  of  the  disease 
at  different  times,  and  on  differences  in  the  treatment  employed. 
Schloss  and  Commiskey  state  that  the  mortality  ranges  from  35  to 
87  per  cent.  For  all  forms  of  the  disease  60  per  cent,  represents  an 
average  mortality.  In  Green  and  Swift's  series  the  mortality  was 
60  per  cent,  in  the  umbilical  type,  50  per  cent,  in  the  sero-mucous  type, 
and  22  per  cent,  in  the  purpuric  type. 

In  any  single  case  the  prognosis  depends  on  the  severity  of  the 
hemorrhage,  the  vigor  of  the  child,  and  the  treatment  employed. 
There  is  no  reason  for  ever  giving  a  hopeless  prognosis,  for  recovery 
can  occur  even  in  the  most  severe  cases. 

TREATMENT.  The  most  effective  weapon  against  hemorrhagic 
disease  of  the  newborn  is  human  blood.  Favorable  results  of  a  con- 
vincing character  have  been  obtained  by  the  use  of  whole  human  blood 
given  both  subcutaneously,  and  intravenously,  and  by  the  use  of 
human  blood  serum. 

Of  the  methods  of  employing  human  blood,  I  believe  that  trans- 
fusion is  the  ideal  one,  because  whatever  the  cause,  transfusion  re- 
stores to  the  infant's  circulation  all  the  elements  needed  for  coagula- 
tion. It  further  corrects  anemia  by  replacing  the  cellular  elements 
which  have  been  lost,  and  dilutes  any  toxin  which  may  be  present  to 
the  greatest  possible  extent.  The  only  objection  to  transfusion  is 
the  difficult  technic  of  the  operation  when  performed  on  newborn 
babies. 

In  view  of  the  convincingly  favorable  reports  of  Schloss  and  Com- 
miskey and  others  on  the  subcutaneous  use  of  whole  human  blood, 
and  those  of  Welch,  confirmed  by  many  others,  on  the  use  of  human 
blood  serum,  these  methods  of  giving  human  blood  deserve  a  place 
in  the  treatment  of  this  disease.  I  beheve  that,  as  suggested  by  Vin- 
cent, a  rational  combination  of  all  three  methods  is  the  best  routine 
treatment  which  can  be  employed. 

In  the  beginning  the  hemorrhages  are  often  trivial,  or  the  infant, 
when  first  seen,  is  not  yet  either  severely  exsanguinated  or  prostrated. 
In  this  stage,  at  the  first  injection,  whole  blood  may  be  used  to  save 
delay.  The  donor  having  been  obtained,  about  60  c.c.  of  blood 
should  be  withdrawn  with  a  sterile  syringe  and  needle  from  the  vein 
at  the  bend  of  the  elbow.  Of  this,  from  10  c.c.  to  30  c.c,  according 
to  the  severity  of  the  hemorrhage,  should  be  injected  subcutaneously 
at  once.  The  rest  should  be  set  aside  to  furnish  serum  for  further 
treatment.     In  the  subsequent  injections,  this  serum  may  be  used, 


Hemorrhagic  Disease  of  the  Newborn 


207 


and  from  lo  to  30  c.c.  may  be  given  every  four  to  eight  hours,  accord- 
ing to  the  course  of  the  case. 

If  the  patient,  when  seen  first,  is  already  so  greatly  prostrated  or 
exsanguinated  as  to  appear  in  a  serious  condition,  or  if  the  injections 
of  whole  human  blood,  or  human  serum  are  not  followed  by  recog- 
nizable improvement,  the  safest  treatment  is  by  transfusion.  Under 
these  circumstances,  whenever  a  surgeon  is  available  who  is  familiar 
with  the  more  formidable  technic  of  this  operation,  direct  transfusion 

should  be  performed. 

Fig.  62 


Dr.  Beth  Vincent's  apparatus  for  transfusing.     Consisting  in  paraffin  treated  tube,  com- 
pression bulb,  and  needle 

Transfusion  is  usually  followed  by  immediate  and  permanent 
cessation  of  the  hemorrhages.  Whenever  the  hemorrhages  once  cease, 
they  are  not  likely  to  recur.  It  should  be  remembered  that  cases  in 
which  hemorrhage  is  due  to  bacterial  infection,  to  syphilis,  or  to 
ulcers  of  the  stomach  and  intestine,  are  not  so  favorable  for  treat- 
ment with  human  blood.  This  may  explain  the  failure  of  treatment 
in  certain  cases. 


208 


Diseases  of  the  Newborn 

Fig.  63 


Obtaining  blood  in  paraffin  treated  tube  from  the  donor  in  transfusion 

Fig.  64 


TRAXSFUSIOX   IX   THE    XEWBORX 

Injecting  blood  from  a  paraffin-coated  tube  into  the  longitudinal  sinus 


Hemorrhagic  Disease  of  the  Newborn  209 

There  are  other  methods  of  treatment  which  have  not,  in  my  opin- 
ion, given  evidence  of  value  sufficiently  convincing  to  warrant  their 
discussion  here.  Of  these  rabbit  serum  has  given  the  best  reports. 
I  believe  the  only  indication  for  its  use  would  be  in  a  case  in  which 
human  blood  or  serum  was  not  obtainable. 

PR0BLE:\IS  and  research.— The  obscure  questions  in  the 
etiology  and  pathology  of  hemorrhagic  disease  of  the  newborn,  have 
been  the  subject  of  considerable  investigation  and  experimental 
research  within  the  last  decade.  The  particular  problems  at  present 
engaging  the  attention  of  investigators  are  two  in  number.  The 
first  problem  is,  what  are  the  changes  or  abnormalities  in  the  tissues 
which  are  concerned  with  this  tendency  to  hemorrhage  in  newborn 
babies?  The  second  problem  is,  what  is  the  cause  of  these  changes 
or  abnormahties?  The  first  problem  is  intimately  connected  with 
the  mechanism  of  the  coagulation  of  the  blood,  for  the  tissue  defect 
must  involve  either  the  blood,  or  the  walls  of  the  blood  vessels. 

The  mechanism  of  blood  coagulation,  while  still  imperfectly  under- 
stood, presents  certain  known  features,  interference  with  which  might 
easily  lead  to  prolonged  and  uncontrollable  hemorrhage.  The  most 
generally  accepted  view  of  the  coagulation  of  the  blood  is  the  follow- 
ing: Coagulation  is  due  to  the  action  of  thrombin  (fibrin  ferment) 
upon  the  fibrinogen  of  the  blood,  or  to  the  union  of  thrombin  and 
fibrinogen.  The  term  fibrin  ferment  is  now  not  so  much  used  as 
formerly,  because  it  is  doubtful  if  thrombin  is  actually  a  ferment; 
its  mode  of  action  is  uncertain.  It  is  fairly  certain,  however,  that 
thrombin  does  not  exist  as  such  in  the  circulating  blood,  but  as  it 
appears  shortly  after  the  blood  is  shed,  all  its  constituents  must  have 
been  present.  The  mother  substance  from  which  thrombin  is  sup- 
posedly formed  is  called  prothrombin,  and  this  is  supposedly  derived 
from  the  blood  platelets,  but  it  has  not  been  isolated.  It  is  theo- 
retically supposed  to  be  held  neutralized  in  the  circulating  blood  by 
antithrombin  (antifibrin  ferment),  which  is  believed  to  have  the  func- 
tion of  preventing  the  occurrence  of  an  extending  coagulum  from  the 
passage  of  thrombin  from  its  original  seat  of  formation.  The  other 
substances  involved  in  the  formation  of  the  thrombin  are  the  calcium 
salts  normally  present  in  the  blood,  and  a  substance  called  throm- 
bokinase,  which  is  liberated  from  the  body  tissues  after  injury.  This 
kinase,  with  the  calcium  salts,  generates  thrombin  from  prothrombin. 
The  mechanism  is  shown  in  the  following  diagram. 


Prothrombin 
+ 
Calcium  Salts  J-Thrombin  ] 

Thrombkinase 


+         [Fibrin  Clot 
Fibrinogen] 


When  all  these  elements  are  present  in  normal  proportion,  a  normal 

14 


210  Diseases  of  the  Newborn 

clot  is  formed.  A  diminution  or  absence  of  any  one  of  them  will 
lead  to  an  inferior  clot,  or  a  delayed,  or  absent  clot.  If  the  calcium 
salts  are  diminished  or  absent,  it  has  been  found  that  the  coagulation 
time  is  prolonged,  or  there  is  no  clot.  If  the  prothrombin  is  absent, 
the  onset  of  the  coagulation  time  will  be  normal,  but  the  clot  will  be 
gelatinous  and  not  firm.  If  the  kinase,  or  fibrinogen,  are  dimished 
or  absent,  the  coagulation  time  will  be  delayed,  with  inferior  clot,  or 
the  blood  will  remain  fluid. 

The  methods  of  investigation  now  in  use,  are  the  following:  Meas- 
urements of  the  coagulation  time;  studies  on  the  firmness  of  the  clot; 
studying  the  effect  of  adding  calcium  salts;  studying  the  effect  of 
adding  defibrinated  normal  human  blood;  studying  the  effect  of  the 
infant's  blood  on  normal  blood;  artificial  extraction  of  thrombin  in 
pure  form. 

The  results  of  these  investigations  have  not  been  uniform,  and  do 
not  point  toward  the  diminution  or  absence  of  any  one  particular 
factor  in  cases  of  hemorrhagic  disease  of  the  newborn.  The  most 
recent  investigations  are  those  of  Schloss  and  Commiskey,  and  of 
Schwartz  and  Ottenburg.  In  some  cases  the  coagulation  time  has 
been  found  markedly  delayed,  and  there  is  evidence  of  an  inferior 
clot.  Such  cases  can  be  explained  on  a  basis  of  deficiency  of  fibrino- 
gen or  of  a.  general  deficiency  of  thrombokinase.  Other  cases  have 
been  found  with  coagulation  times  which  are  only  slightly  delayed 
or  are  normal.  In  cases  with  normal  coagulation  time,  but  in  which 
puncture  of  the  skin  is  followed  by  excessive  bleeding,  it  is  possible 
that  the  deficiency  lies  in  the  prothrombin.  In  three  of  Schloss  and 
Commiskey's  cases,  however,  the  coagulation  was  normal,  and  there 
was  no  bleeding  from  punctures  of  the  skin,  hemorrhage  being  quickly 
controlled  by  a  firm  well  contracted  clot.  The  writers  attribute  the 
hemorrhage  in  these  cases  to  some  localized  vascular  lesion,  and 
believe  the  lesion  may  possibly  be  a  local  absence  or  interference 
with  the  action  of  thrombokinase,  which  is  normally  liberated  upon 
injury  to  the  vessel  wall.  There  is  no  well  supported  evidence  that 
deficiency  in  calcium  salts  plays  any  part  in  this  hemorrhagic  disease. 

The  question  as  to  whether  the  tissue  defect,  whether  it  lie  in  the 
blood  or  in  the  walls  of  the  vessels,  is  due  to  incomplete  development 
or  to  infection  is  less  susceptible  of  experimental  investigation.  The 
argument  in  favor  of  the  developmental  theory,  is  that  the  tendency 
to  hemorrhage  is  seen  only  in  the  early  days  of  life,  and  does  not 
persist.  There  is,  however,  a  certain  tendency  to  obscure  infection 
which  also  is  only  seen  in  the  newborn.  Those  who  believe  in  the 
developmental  theory  point  to  the  absence  in  most  cases  of  clin- 
ical, anatomical,  or  bacteriologic  signs  of  infection. 

Nevertheless  there  is  an  increasing  tendency  to  attribute  this 
disease  picture  to  infection.     It  is  known  that  hemorrhage  is  a  com- 


Hemorrhagic  Disease  of  the  Newborn  211 

paratively  common  symptom  of  some  well-recognized  infections  of 
the  newborn.  The  evidence  against  the  infectious  theory  is  of  a 
purely  negative  character,  while  on  the  other  hand,  considerable 
evidence  has  recently  been  accumulated  tending  to  substantiate  this 
infectious  theory.  The  disease  is  most  apt  to  be  seen  in  institutions. 
Green  and  Swift  have  pointed  out  the  tendency  of  the  disease  in 
their  series  of  hospital  cases  to  occur  in  groups,  and  believe  that  this, 
together  with  the  seasonal  incidence,  tends  strongly  to  confirm  the 
theory  of  an  infectious  etiology.  Moreover,  a  number  of  observers 
have  isolated  bacteria  of  various  kinds  from  certain  of  these  cases. 
A  certain  number  of  cases  show  a  distinct  febrile  reaction.  The 
self-limited  character  of  the  disease  is  often  brought  forward  in  sup- 
port of  the  infectious  theory,  but  goes  very  well  with  the  theory  of 
incomplete  tissue  development. 

We  can  only  look  to  further  investigations  for  the  solution  of 
these  problems.  The  attempt  to  determine  the  pathology  of  the 
blood  in  hemorrhagic  conditions  is  beset  with  numerous  obstacles, 
and  it  is  improbable  that  the  exact  causation  of  hemorrhage  in  the 
newborn  can  be  definitely  ascertained  until  the  physiologic  processes 
of  blood  coagulation  are  more  thoroughly  understood.  It  is  quite 
probable  that,  as  in  many  functional  disturbances,  several  different 
conditions  may  be  concerned  in  the  etiology,  any  one  of  which  may 
be  the  cause  of  a  particular  case  of  hemorrhage. 

A  number  of  methods  of  treatment  will  be  found  recommended  in 
the  literature  of  hemorrhage  in  the  newborn,  each  based  on  some 
particular  theory  of  the  etiology  of  the  condition,  and  each  with 
clinical  evidence  in  its  support.  Among  the  various  measures  which 
have  been  recommended  are  the  following:— -Injections  of  gelatine; 
administration  of  calcium  salts;  administration  of  adrenalin;  sub- 
cutaneous injection  of  horse  serum;  subcutaneous  injection  of  rabbit 
serum.  We  have  seen,  however,  that  no  exclusive  theory  of  the 
pathogenesis  of  this  disease  is  tenable.  Chnical  evidence  in  any 
single  case  can  be  explained  by  the  fact  that  some  cases  will  recover 
without  treatment. 

The  use  of  gelatin  is  entirely  empirical,  and  it  has  been  finally 
proven  to  be  inert  in  its  power  to  increase  the  coagulability  of  the 
blood,  either  in  vitro  or  in  vivo.  Adrenalin  has  also  been  found  to 
be  inert,  having  value  only  as  a  local  hemostatic.  Calcium  salts  have 
been  found  to  increase  the  coagulability  of  the  blood  in  test-tube 
experiments,  but  it  has  been  found  that  only  the  ionizable  calcium 
salts  of  the  blood  enter  into  blood  coagulation,  and  these  can  be 
only  very  slightly  increased  by  administering  calcium  salts  to  a 
patient.  Deficiency  of  calcium  salts,  also,  does  not  appear  to  play 
an  etiologic  role  in   this  particular   disease.     Of   the   animal   sera. 


212  Diseases  of  the  Newborn 

experiment  has  shown  that  horse  serum  is  less  potent  than  rabbit 
serum,  but  that  rabbit  serum  is  less  potent  than  human  serum. 

ICTERUS  NEONATORUM 

Jaundice  is  a  symptom  seen  with  great  frequency  in  newborn 
infants.  In  the  majority  of  cases  the  jaundice  is  of  so  slight  a  grade, 
and  is  characterized  by  so  entire  an  absence  of  pathological  symp- 
toms, that  it  is  usually  looked  upon  as  representing  a  physiological 
process  which  is  normal  in  the  early  days  of  life.  This  type  of  jaun- 
dice is  called  Icterus  Neonatorum. 

There  are,  however,  a  number  of  other  conditions,  of  true  patho- 
logical nature,  which  are  characterized  by  the  appearance  of  jaun- 
dice in  newborn  babies.  These  more  serious  conditions,  though  rare, 
must  be  carefully  distinguished  from  the  common  icterus  neonatorum. 
In  the  first  place,  jaundice  is  a  not  infrequent  symptom  of  infection 
in  newborn  babies;  it  is  also  sometimes,  though  rarely,  a  symptom 
of  congenital  syphilis.  It  is  the  chief  symptom  of  a  congenital  cirrhosis 
of  the  liver,  which  has  been  found  at  autopsy,  and  of  congenital  oblitera- 
tion of  the  bile  ducts.  This  last  condition  may  represent  a  congenital 
malformation,  or  may  represent  a  late  stage  of  congenital  cirrhosis. 
Catarrhal  jaundice,  an  obstructive  form,  in  which  the  cause  is  swelling 
of  the  mucosa  of  the  bile  ducts,  is  very  rare  in  newborn  babies,  but 
is  still  a  possibility.  Finally,  certain  cases  of  jaundice  have  been 
observed  in  newborn  babies,  in  which  all  the  above  causes  were 
absent,  and  in  which  no  cause  was  found. 

Icterus  neonatorum  is  by  far  the  commonest  condition  producing 
jaundice  in  the  first  days  of  life.  It  has  been  variously  reported  to 
exist  in  from  40  to  80  per  cent,  of  all  newborn  infants. 

ETIOLOGY. — The  etiology  of  icterus  neonatorum  remains  ob- 
scure, in  spite  of  the  fact  that  it  has  been  the  subject  of  much  inge- 
nious speculation.  The  most  satisfactory  explanation  is  that  of 
Abramow,  who  considers  the  jaundice  due  to  an  anomaly  of  secre- 
tion of  the  hver  cells.  Shortly  after  birth,  as  the  result  of  the  rich 
supply  of  blood  to  the  liver,  the  hepatic  cells  produce  bile  more 
rapidly  than  it  can  escape.  The  bile  capillaries  at  birth  are  over- 
filled with  a  thick  and  tenacious  bile,  which  obstructs  its  own  flow 
as  it  is  formed'  so  rapidly.  The  bile,  consequently,  passes  into  the 
blood  capillaries,  and  thence  into  the  general  circulation.  This  ex- 
planation is  in  accordance  with  the  theory  that  icterus  neonatorum  is 
a  physiological  and  not  a  pathological  process. 

SYMPTOMS.  —  The  jaundice  is  not  present  at  birth,  but  develops 
usually  on  the  second  or  third  day.  It  is  first  noticed  on  the  face  and 
chest,  then  in  the  conjunctivae,  then  on  the  extremities.     It  increases 


PLATE  II. 


Icterus  Neonatorum. 


Red  Bone  Marrow.     Natural  Size 


XP  i 


Yellow  Bone  Marrow.     Three-fourths  Natural  Size. 


^W 


Erythema  Neonatorum. 


Icterus  Neonatorum  213 

in  severity  for  three  or  four  days,  then  rather  rapidly  disappears. 
In  rare  cases  it  may  last  longer.  The  color  is  usually  a  pale  yellow, 
but  at  times  is  more  intense.  The  fecal  discharges  are  not  light  col- 
ored, and  contain  bile  pigment.  The  urine  in  most  cases  is  normal, 
not  showing  bile  pigment,  though  sometimes  the  presence  of  bile 
pigment  can  be  demonstrated  by  special  tests.  There  is  no  en- 
largement of  the  liver  or  spleen,  and  no  rise  of  temperature.  The 
general  condition  is  not  affected;  there  are  no  symptoms  of  indiges- 
tion, and  icteric  babies  show  no  tendency  to  gain  weight  less  rapidly. 

DIAGNOSIS.— The  recognition  of  the  condition  is  very  easy. 
The  absence  of  all  other  signs  of  disease,  together  with  the  normal 
stools,  serve  to  differentiate  icterus  neonatorum  from  the  other 
conditions  in  which  jaundice  is  seen  in  the  newborn. 

PROGNOSIS.     The  prognosis  is  good. 

TREATMENT.— None  is  required. 

PROBLEMS  AND  RESEARCH.— A  number  of  theories  as  to 
the  cause  of  icterus  neonatorum  have  been  advanced,  and  disproved, 
although  references  to  them  are  still  to  be  met  with  in  medical  litera- 
ture. Among  these  disproven  theories  are  the  following: — Frank's 
theory  that  the  cause  of  jaundice  is  plugging  of  the  common  bile 
duct  with  mucous  and  cast-off  epithelium;  Birch-Hirschf eld's  assump- 
tion of  an  edema  of  Ghsson's  capsule;  Bouchet's  hypothesis  of  a 
hepatitis;  Epstein's  theory  of  a  catarrh  of  all  the  bile  ducts.  Quincke's 
theory  of  a  patent  ductus  venosus  is  improbable. 

The  hematogenic  factor  in  the  etiology  of  icterus  neonatorum  is 
still  under  discussion.  The  many  supporters  of  this  theory  assume 
that  there  is  in  the  early  days  of  Hfe  a  countless  destruction  of  erythro- 
cytes, which  produces  polycholia  and  jaundice.  This  theory  has  been 
refuted,  the  apparent  destruction  of  red  blood  corpuscles  being  attrib- 
uted to  an  increase  in  plasma.  Still  more  recently,  evidence  has 
been  brought  forward  to  show  that  the  destruction  of  erythrocytes 
actually  does  occur.  Even  if  this  evidence  is  true,  it  only  furnishes 
plausible  explanation  of  the  increased  bile  formation  in  the  early 
days  of  hfe,  which  must  otherwise  be  attributed  to  a  rapid  awakening 
of  the  function  of  the  hepatic  cells. 

The  only  experimental  work  which  has  been  done  in  this  condition 
is  that  of  Hess,  who  investigated  cases  of  icterus  neonatorum  with  the 
duodenal  catheter.  He  found  that  bile  is  excreted  into  the  duo- 
denum very  rarely  in  the  first  twelve  hours  of  life.  In  the  next 
twenty-four  hours,  bile  excretion  is  variable,  being  profuse  in  cases 
with  marked  jaundice,  and  scanty  or  absent  in  cases  not  jaundiced. 
He  found  that  jaundice  precedes  the  excretion  of  bile  into  the  duo- 
denum, and  is  more  marked  in  cases  with  profuse  secretion.  Hess 
believes  that  the  cause  of  icterus  neonatorum  is  due  to  the  fact  that 


214 


Diseases  of  the  Newborn 


the  mechanism  of  bile  excretion  into  the  duodenum  is  not  well  equipped 
in  the  earliest  days  of  Hfe.  Excess  of  bile  is  secreted,  whether  or  not 
the  cause  is  an  increased  amount  of  available  hemoglobin.  Excre- 
tion becomes  profuse,  but  not  enough  to  take  care  of  the  excess, 
with  resulting  congestion  of  the  bile  capillaries. 

CONGENITAL  CIRRHOSIS  OF  THE  LIVER, 

CONGENITAL  OBLITERATION  OF  THE  BILE  DUCTS 

These  conditions,  while  described  by  many  writers  as  separate 
diseases,  are  here  described  together,  because  the  preponderance  of 
evidence  points  to  so  close  an  association  between  them,  that  many 
authorities  believe  them  to  be  different  stages  of  the  same  process, 
and  because  their  clinical  manifestations  are  practically  identical. 


Fig.  65 


Congenital  cirrhosis  of  the  liver 

PATHOLOGICAL  ANATOMY.— In  the  majority  of  the  reported 
cases,  there  is  found  at  autopsy  complete  obliteration  of  some  part 
of  the  extra-hepatic  bile  ducts.  In  the  majority  of  cases  the  com- 
mon duct  is  obHterated,  usually  down  to  and  including  the  opening 
of  the  papilla  of  Vater.     The  obliteration  usually  also  involves  the 


Congenital  Obliteration  of  the  Bile  Ducts 


215 


hepatic  ducts.  The  cystic  duct  may  be  obHterated,  or  its  lumen 
may  be  much  narrowed.  The  obhterated  ducts  are  usually  rep- 
resented by  a  fibrous  cord,  but  may  be  entirely  absent.  The  gall 
bladder  is  frequently  very  small,  and  is  sometimes  also  obhterated, 
and  replaced  by  fibrous  tissue. 

Accompanying  this  condition  of  obliteration  of  the  bile  ducts,  there 
are  always  found  marked  changes  in  the  liver.  The  principal  lesion 
is  a  cirrhosis,  of  the  biliary  type,  characterized  by  an  increase  in  con- 
nective tissue,  which  is  most  marked  in  the  region  of  the  portal 
vessels,  but  which  often  occurs  to  a  varying  extent  dift'usely  within 


Congenital  cirrhosis  of  the  liver.     Section  showing  increase  in  fibrous  tissue  and  invasion 

of  the  lobules 


the  lobules.  The  connective  tissue  varies  in  age,  in  some  cases 
appearing  comparatively  newly  formed,  in  other  cases  old  and  dense. 
The  changes  in  the  liver  cells  show  marked  variations  in  different 
cases.  In  some  the  cells  remain  arranged  in  orderly  trabeculae,  in 
others  some  of  them  are  much  increased  in  size,  in  still  others  they 
show  marked  atrophy  or  extensive  destruction.  The  bile  capillaries 
are  usually  much  distended  and  many  contain  inspissated  bile. 
There  are  often  newly  formed  bile  capillaries  to  be  seen. 


216  Diseases  of  the  Newborn 

Two  views  are  held  as  to  the  pathogenesis  of  the  cases  in  which 
obhteration  of  the  bile  ducts  is  found.  One  view  regards  this  lesion 
as  developmental  in  origin,  a  congenital  malformation.  The  other 
view  regards  the  lesion  as  due  to  an  inflammatory  process,  leading 
to  fibrous  tissue  formation  and  obliteration.  It  is  possible  that  in 
some  instances  the  condition  may  represent  a  congenital  malforma- 
tion, but  such  instances  are  certainly  extremely  rare.  It  is  probable 
that  in  the  majority  of  cases  the  obliteration  of  the  ducts  is  due  to 
inflammation. 

Two  views  are  also  held  as  to  the  relation  of  the  cirrhotic  process 
in  the  liver  to  the  obliteration  of  the  bile  ducts.  One  view  regards 
the  bile  duct  process,  whether  inflammatory  or  developmental,  as 
primary,  and  considers  the  cirrhosis  of  the  liver  as  a  secondary  pro- 
cess. The  other  view  regards  the  process  in  the  liver,  cholangitis 
and  cirrhosis,  as  primary,  and  considers  that  the  occlusion  of  the 
bile  ducts  is  due  to  an  extension  of  this  tissue  reaction  down  along 
the  large  bile  ducts.  In  favor  of  this  latter  view  is  the  fact  that 
obliteration  of  the  extrahepatic  bile  ducts  is  never  found  without 
an  accompanying  cirrhosis  of  the  liver,  but  on  the  other  hand  many 
cases  have  been  reported  in  which  precisely  the  same  cirrhosis  was 
found  in  the  liver,  but  in  which  the  common  and  hepatic  ducts  were 
found  patulous  throughout  their  entire  extent.  While  the  changes 
in  the  liver  do  not  resemble  those  generally  described  as  occurring 
after  sudden  obstruction  to  the  flow  of  bile,  it  is  usually  difficult  to 
tell  which  process  is  primary.  There  is  anatomical,  evidence  on 
either  side,  and  it  is  quite  possible  that  either  lesion  may  be  the 
primary  one. 

The  two  conditions  are  certainly  so  closely  connected  that  they 
cannot  well  be  considered  as  distinct  diseases. 

ETIOLOGY. — The  cause  of  the  condition  is  unknown,  and  very 
possibly  varies  with  the  case.  Congenital  syphiHs  is  probably  not 
an  etiological  factor.  If  we  exclude  those  cases,  certainly  rare,  in 
which  the  obliteration  of  the  bile  ducts  may  represent  a  congenital 
malformation,  the  prevailing  view  is  that  the  inflammatory  process 
is  due  to  the  absorption  of  toxic  substances  from  the  mother,  and 
this  theory  is  unafl'ected  by  the  question  as  to  whether  the  liver 
or  the  bile  ducts  are  first  affected.  This  theory  is  of  course,  with- 
out proof. 

SYMPTOMS. — The  most  striking  symptom  is  jaundice,  which  is 
sometimes  present  at  birth,  but  which  usually  develops  on  the  second 
or  third  day,  and  sometimes  not  until  the  fourth  day.  The  jaundice 
increases  rapidly,  and  soon  becomes  intense,  so  that  the  skin  appears 
of  a  greenish-yellow  tint.  The  stools  may  or  may  not  be  composed 
of  meconium  at  birth,  according  to  the  period  of  fetal  development 


Congenital  Obliteration  of  the  Bile  Ducts  217 

when  the  obstruction  occurred.  Meconium  is  usually  seen,  but  very 
soon  the  dejecta  become  white  or  clay  colored.  In  the  majority 
of  cases,  bile  pigment  is  not  to  be  demonstrated  in  the  stools  by  a  chem- 
ical test.  In  some  cases,  however,  bile  pigment  has  been  found 
present,  these  cases  being  usually  those  conditions  in  which  congenital 
cirrhosis  exists  without  obUteration  of  the  bile  ducts.  Nevertheless, 
I  have  recently  seen  a  case  in  which  no  obliteration  of  the  ducts  was 
found  at  autopsy,  with  bile  pigment  constantly  absent  in  the  stools, 
while  Hess  has  recently  reported  a  case  with  complete  obliteration  of 
the  common  duct,  in  which  the  stools  contained  traces  of  bile  pigment, 
which  proves  the  possibility  of  excretion  of  bile  from  the  circulation 
through  the  intestinal  wall.  The  stools  always  show  defective  absorp- 
tion of  the  fat  given  in  the  food. 

The  urine  is  always  dark,  and  contains  bile.  The  liver  and  spleen 
are  usually  enlarged,  although  not  always,  especially  in  cases  where 
cirrhosis  of  the  Hver  is  very  marked.  Hemorrhages  may  be  seen  in 
the  early  days  of  life,  or  late  in  the  course  of  the  disease. 

The  babies  lose  steadily  in  weight  and  strength.  Symptoms  of 
indigestion  may  be  present,  but  are  usually  notably  less  marked 
than  one  would  expect.  In  fact  the  general  condition,  for  quite  a 
time  after  the  development  of  the  symptoms,  remains  much  better 
than  would  be  expected  in  a  condition  with  such  serious  lesions. 
Finally,  however,  malnutrition  becomes  extreme,  and  death  occurs 
from  inanition,  or  from  some  intercurrent  infection. 

DIAGNOSIS. — Icterus  neonatorum  is  easily  excluded  in  these 
cases,  on  account  of  its  mild  and  brief  type  of  jaundice,  and  the 
fact  that  the  stools  and  urine  remain  normal.  The  conditions  to  be 
particularly  considered  in  diagnosis  are  infectious  disease  of  the  new- 
born with  jaundice  as  a  symptom,  and  catarrhal  jaundice.  When 
jaundice  is  a  symptom  of  infection,  the  temperature  is  usually  ele- 
vated, and  not  infrequently  high  and  irregular.  The  general  con- 
dition is  usually  more  profoundly  affected  from  the  start.  The 
physical  examination  frequently  gives  definite  information  as  to  the 
source  and  location  of  the  septic  process.  The  jaundice  is  often 
not  quite  so  intense.  The  most  important  point,  however,  is  that 
the  movements  in  sepsis  are  not  light  colored,  and  contain  bile. 

It  is  more  difficult  to  exclude  catarrhal  jaundice,  although  this 
condition  is  extremely  rare  in  the  early  days  of  hfe.  Catarrhal 
jaundice  may  show  the  same  intense  icterus,  with  absence  of  bile 
in  the  stools.  Even  when  it  is  seen  early  in  life,  it  usually  develops 
at  a  somewhat  later  period  after  birth.  In  such  a  case,  with  com- 
paratively late  development,  and  with  absence  of  enlargement  of  the 
liver,  catarrhal  jaundice  may  be  suspected.  The  diagnosis  can  be 
confirmed  only  by  the  favorable  course  of  the  disease. 


218  Diseases  of  the  Newborn 

PROGNOSIS. — The  prognosis  of  congenital  cirrhosis  and  obhtera- 
tion  of  the  bile  ducts  is  bad.  Some  cases  die  in  the  early  weeks;  others 
may  survive  for  several  months.  Eight  months  is  the  longest  recorded 
period  of  survival. 

TREATMENT. — Careful  feeding  is  the  only  treatment  which  can 
be  employed  in  these  cases.  Milk  modifications  in  artificially  fed 
infants  should  be  low  in  fat,  high  in  protein. 

In  cases  in  which  the  diagnosis  is  fully  established  by  the  persis- 
tence of  signs  of  complete  obstruction  to  the  flow  of  bile,  I  beheve 
that  a  surgical  exploration  should  be  considered.  Such  an  operation 
will  probably  shorten  the  life  of  the  baby,  if  the  diagnosis  is  correct. 
On  the  other  hand,  there  is  a  possibiHty  of  the  jaundice  being  due  to 
some  remediable  condition,  such  as  mechanical  obstruction  of  the 
large  ducts  from  pressure  of  glands,  inspissated  bile,  or  peritoneal 
adhesions.  The  absolutely  hopeless  prognosis  makes  it  justifiable  to 
take  advantage  of  the  possibihty,  even  though  remote,  of  a  mistake 
in  diagnosis. 

PROBLEMS  AND  RESEARCH.— The  problems  of  the  cause  of 
the  tissue  changes,  whether  they  are  due  to  a  malformation,  or  to 
the  intrauterine  absorption  of  toxin  from  the  mother,  and  of  the 
location  of  the  primary  lesions,  are  not  very  promising  for  experi- 
mental investigation.  Possibly  the  continued  study  of  pathological 
material,  together  with  thorough  and  continued  observations  on  the 
presence  of  bile  in  the  duodenum  or  stools  throughout  the  Hfe  of  the 
baby,  may  eventually  give  more  Hght.  The  method .  of  studying 
the  contents  of  the  duodenum  by  means  of  the  duodenal  catheter, 
as  described  and  practiced  by  Hess,  is  particularly  worthy  of  men- 
tion in  this  connection.  Hess  has  further  called  attention  to  the 
role  of  the  pancreas  in  this  disease.  He  finds  that  the  pancreatic 
duct  of  Wirsung  is  frequently  obHterated  at  its  opening,  when  the 
common  bile  duct  obhteration  involves  the  papilla  of  Vater,  but  that 
the  pancreatic  ferments  may  nevertheless  be  found  undiminished  in 
the  contents  of  the  duodenum  obtained  by  the  duodenal  catheter. 
In  these  cases  the  obliteration  of  the  duct  of  Wirsung  is  compensated 
by  the  presence  of  the  accessory  duct  of  Santorini,  and  the  prog- 
nosis as  to  duration  of  hfe  is  probably  better  than  in  cases  in  which 
no  accessory  pancreatic  duct  exists. 

SCLEREMA 

Sclerema  neonatorum  is  a  rare  condition,  characterized  by  pro- 
gressive hardening  of  the  skin  and  subcutaneous  tissues. 

ETIOLOGY. — Sclerema  is  seen  most  frequently  in  premature  or 
very  feeble  infants.  While  it  is  commonest  in  the  early  days  of 
life,  it  is  not  exclusively  a  disease  of  the  newborn,  as  it  may  be  seen 


Sclerema  219 

at  any  time  in  the  first  few  months  in  infants  weakened  by  malnu- 
trition, diarrhea,  or  some  acute  infection.  In  the  newborn  it  is 
most  frequently  found  among  those  who  are  born  in  exceedingly 
poor  hygienic  surroundings,  and  in  cold  weather.  The  cause  is  prob- 
ably general,  a  number  of  factors  being  involved,  such  as  great  feeble- 
ness with  weakness  of  circulation,  loss  of  fluid  from  the  skin,  lower- 
ing of  the  body  temperature,  and  hardening  of  the  subcutaneous  fat. 

PATHOLOGICAL  ANATOMY.— Although  Northrup  reported  a 
case  clinically  topical,  in  which  microscopic  examination  of  the  skin 
revealed  nothing  abnormal,  the  majority  of  writers  have  reported 
changes  in  the  skin.  These  changes,  however,  show  nothing  peculiar 
to  the  disease,  and  may  not  be  an  essential  feature.  Various  degrees 
of  atrophy  of  the  subcutaneous  connective  tissue  appears  to  be  the 
chief  lesion  described. 

SYMPTOMS. — Soon  after  birth,  spots  of  circumscribed  hardness 
appear  on  the  skin.  These  spots  soon  become  diffuse,  and  the  disease, 
starting,  as  it  usually  does,  in  the  feet  or  the  calves  of  the  legs,  passes 
up  the  thighs  to  the  trunk.  It  may,  however,  first  appear  upon  the 
face  and  upper  extremities,  though  not  commonly.  The  skin  is  waxy 
and  ghstening,  and  is  hard  and  cold;  the  limbs  become  thick,  stiff, 
and  misshapen.  The  infant  soon  grows  weak  and  somnolent,  and 
refuses  to  take  its  food;  the  breathing  becomes  rapid  and  superficial, 
the  voice  is  weak  and  whimpering,  and  the  pulse  small  and  retarded. 
The  temperature  is  markedly  subnormal  and  death  takes  place  seem- 
in  glv  from  inanition. 


^b^J 


DIAGNOSIS. — Sclerema  presents  so  definite  a  clinical  picture, 
that  the  diagnosis  is  usually  easy.  It  must  be  distinguished  from 
the  edema  occasionally  seen  in  newborn  babies.  In  sclerema  the 
skin  is  harder,  and  does  not  pit  on  pressure. 

PROGNOSIS. — The  outlook  in  sclerema  is  very  bad,  because  of 
the  grave  character  of  the  etiologic  factors.  It  is  usually,  but  not 
invariably  fatal. 

TREATMENT. — Artificial  heat  is  the  most  important  thing  in 
the  treatment.  The  incubator  or  incubator-bed  must  be  used.  The 
nutrition  must  be  maintained  as  well  as  possible  by  careful  feeding. 

EDEMA 

Edema  is  occasionally  seen  in  early  infancy.  In  a  certain  number 
of  cases,  edema  is  a  symptom  of  some  severe  disease,  such  as  septic 
infection,  syphilis  of  the  internal  organs,  pulmonary  diseases,  and 
severe  gastro-intestinal  disturbances.  There  is  a  form  to  which  the 
name  Oedema  Neonatorum  may  be  applied,  which  is  not  sympto- 
matic of  any    recognizable    disease    process.     This   edema  is   seen 


220  Diseases  of  the  Newborn 

most  frequently  in  premature  or  congenitally  feeble  infants,  and 
appears  usually  on  the  first  day  of  life.  The  edema  appears  first 
in  the  suprapubic  zone,  then  involves  the  legs  and  sexual  organs, 
and  is  occasionally  seen  on  the  backs  of  the  hands.  It  is  never 
general.  There  are  two  stages  in  its  development;  in  the  first  the 
tissue  appears  overfilled  with  fluid,  but  does  not  pit  on  pressure; 
in  the  second,  there  are  the  usual  signs  of  edema  with  pitting.  It 
lasts  usually  but  a  few  days;  the  longest  recorded  case  lasted  twenty 
days.  Any  deviation  from  the  typical  development  is  suggestive 
of  symptomatic  edema  from  one  of  the  other  causes.  Edema 
neonatorum,  however,  may  pass  over  into  one  of  the  other  forms. 
Its  prognosis  and  treatment  is  that  of  congenitally  feeble  and  pre- 
mature infants. 


VI.     INFECTIONS 

INFECTIOUS  DISEASE  OF  THE  NEWBORN 

The  condition  described  under  this  name  is  one  of  general  sepsis 
in  newborn  babies  in  which  the  infecting  microorganisms  enter  the 
blood  and  internal  organs  of  the  newborn  infant. 

The  infant,  even  in  the  early  days  of  Hfe,  may  suffer  from  any  of 
the  common  infectious  diseases.  The  manifestations  of  these  in- 
fections in  newborn  infants  do  not  differ  in  any  essential  particular 
from  those  seen  at  a  later  period  of  life.  In  addition  to  the  recognized 
infectious  diseases,  such  as  pneumonia,  influenza,  typhoid,  and  so 
forth,  there  are  other  infectious  conditions  seen  in  the  newborn 
which  are  caused  by  the  various  pyogenic  microorganisms,  such  as 
the  streptococcus  pyogenes,  the  staphylococcus  pyogenes  aureus 
and  albus,  the  gonococcus,  the  pneumococcus,  the  bacillus  pyocya- 
neus,  the  colon  bacillus,  and  other  rarer  forms.  These  microor- 
ganisms may  form  only  localized  lesions  at  the  portal  of  entrance, 
without  any  general  condition  of  sepsis  supervening.  Such  infec- 
tions show  themselves  in  the  form  of  abscess  formation,  cellulitis, 
and  similar  lesions,  which  differ  in  no  essential  from  the  same  lesions 
seen  at  a  later  period  of  life.  Omphalitis  or  inflammation  about  the 
umbilicus,  and  erysipelas  are  among  the  most  noteworthy  of  these 
external  infections.  Even  when  the  organisms  penetrate  within  the 
body,  they  may  still  give  rise  to  a  localized  inflammatory  process  of 
which  the  pathology  shows  no  features  peculiar  to  newborn  infants. 
Among  these  lesions  are  to  be  numbered  especially  peritonitis,  pneu- 
monia and  pleuritis,  pericarditis,  meningitis,  gastro-enteritis,  osteo- 
myelitis, and  septic  arthritis.  The  clinical  manifestations  of  these 
conditions  are  often  obscure,  so  that  the  diagnosis  is  rather  more 
difficult  in  newborn  infants.  Nevertheless  the  symptoms  do  not 
present  any  features  sufficiently  peculiar  to  the  early  days  of  life 
to  warrant  their  separate  description.  The  localizing  signs  may  be 
less  marked,  so  that  the  clinical  picture  is  one  of  a  general  infection. 
On  the  other  hand  the  presence  of  a  general  infection  may  be  masked 
by  the  prominence  of  localizing  signs. 

A  general  condition  of  infection,  a  true  bacteremia  or  pyemia,  is 
a  particularly  common  manifestation  of  infection  in  newborn  infants. 
The  manifestations  of  such  an  infection  are  so  peculiar  in  the  new- 
born, that  they  call  for  a  detailed  description,  and  it  is  to  this  con- 
dition that  the  term  Infectious  Disease  of  the  Newborn  is  here  applied. 

ETIOLOGY. — The  microorganisms  concerned  in  infectious  disease 


222  Diseases  of  the  Newborn 

of  the  newborn  are  the  pyogenic  types  already  mentioned.  Infection 
occurs  when  from  any  source  these  microorganisms  are  brought  to 
any  of  the  portals  of  entry  which  are  open  in  a  newborn  child  whose 
resistance  is  not  sufficient  to  prevent  their  entrance.  I  do  not  beheve 
that  the  low  general  resistance  of  the  newborn  infant  is  so  great  a 
factor  in  the  occurrence  of  infectious  disease  as  is  generally  stated. 
If  the  infant's  general  resistance  to  infection  were  so  very  low,  infec- 
tion would  be  relatively  much  more  common. 

The  most  important  factor  is  the  relatively  open  condition  in  the 
newborn  infant  of  certain  portals  of  entry,  particularly  the  umbihcal 
wound.  It  is  true  that  in  a  large  number  of  cases  of  infectious  disease 
of  the  newborn  the  portal  of  entry  cannot  be  discovered,  but  there  is 
httle  doubt  that  in  most  of  these  the  infection  is  of  umbihcal  origin. 
That  every  newborn  baby  has  an  open  wound,  which  is  closely  con- 
nected with  the  general  circulation  through  the  anatomical  connec- 
tions of  the  umbihcal  vessels,  is  adequate  explanation  for  the  fre- 
quency and  pecuharities  of  this  type  of  infection  in  newborn  infants. 

At  the  umbihcus,  the  stump  of  the  cord  is  undergoing  a  necrotic 
disintegration  with  which  may  be  associated  pyogenic  organisms. 
In  the  Hgated  umbihcal  veins  are  formed  thrombi  which  may  easily 
become  infected,  and  as  a  result  may  break  down  into  purulent 
material.  As  a  result  of  such  a  septic  phlebitis  the  infected  material 
may  enter  the'  circulation  and  produce  a  general  septicemia,  while 
infected  emboh  may  be  carried  to  any  organ  in  the  body.  All  these 
processes  may  go  on  without  any  lesion  being  noted  at  the  umbilicus, 
and  therefore  it  is  wise,  in  any  case  of  infectious  disease  of  the  new- 
born, to  regard  the  umbihcus  as  the  probable  portal  of  entry. 

There  are  undoubtedly  other  portals  of  entry  in  certain  cases. 
The  organisms  may  enter  through  abrasions  of  the  skin  or  mucous 
membranes,  through  the  lungs,  through  the  mouth,  and  in  rare 
instances  through  the  eye,  ear,  or  genital  tract. 

It  is  probable  that  even  in  umbihcal  infection,  the  organisms  are 
not  those  normally  associated  with  the  disintegration  of  the  cord, 
but  that  the  umbihcal  cord  is  inoculated  with  organisms  of  a  par- 
ticularly pyogenic  nature.  Such  inoculation  is  also  the  probable 
means  of  infection  through  the  other  portals  of  entry.  The  sources 
of  such  inoculation  are  the  vaginal  discharges  of  the  mother,  unclean 
hands  of  nurse  or  physician,  improper  care  of  the  umbihcal  wound, 
dirty  bath  water,  dirty  clothing,  in  short,  any  agent  which  may  carry 
septic  organisms  to  the  portal  of  entry.  In  cases  of  infection  through 
the  lungs  or  intestinal  canal,  it  is  probable  that  infected  mucus  or 
liquor  amnii  may  reach  these  respective  portals  of  entry  in  the  in- 
fant's first  movements  of  respiration  or  of  deglutition.  In  rare 
instances  septic  infection  may  be  transferred  directly  from  an  in- 
fected mother  to  the  fetus  through  the  placental  circulation. 


Infectious  Disease  of  the  Newborn  223 

PATHOLOGICAL  ANATOMY.— The  lesions  of  infectious  disease 
of  the  newborn  show  no  essential  peculiarities  differing  from  pyo- 
genic infection  at  other  periods  of  life.  Umbilical  arteritis  or  phle- 
bitis are  the  most  frequent  lesions.  The  liv^er  is  the  organ  which 
most  frequently  shows  pathologic  changes,  as  one  would  expect 
from  the  frequency  of  umbilical  infection.  In  the  liver  there  may 
be  suppurative  processes,  or  various  degenerative  changes.  Similar 
degenerative  changes  are  found  in  most  of  the  parenchymatous 
organs,  while  individual  foci  of  suppuration  may  have  almost  any 
distribution.     Hemorrhages  are  common. 

Associated  with  these  generally  distributed  lesions,  there  are 
usually  also  localized  lesions,  the  most  common  of  which  is  perito- 
nitis. Pneumonia,  pleuritis,  meningitis,  encephalitis,  pericarditis, 
osteomyelitis,  and  arthritis  are  also  found. 

There  is  a  condition  in  which  the  particular  group  of  lesions  have 
lead  to  its  description  as  a  separate  disease,  under  the  name  of  Fatty 
Degeneration  of  the  Newborn  or  Buhl's  Disease.  The  pathological 
changes  are  essentially  a  parenchymatous  inflammation,  followed  by 
fatty  degeneration  of  the  heart,  liver  and  kidneys,  together  with 
multiple  hemorrhages  in  the  various  organs.  Although  the  nature 
and  cause  of  this  condition  are  unknown,  it  was  first  described  before 
the  advent  of  modern  methods  of  bacteriological  study.  Both  the 
lesions  and  clinical  features  of  this  disease  show  no  essential  differ-, 
ence  from  those  of  pyogenic  infection,  and  it  is  probable  that  it  merely 
represents  a  particular  grouping  of  the  lesions  in  infectious  disease  of 
the  newborn. 

SYMPTOMS. — The  clinical  manifestations  of  infectious  disease 
of  the  newborn  present  great  variations.  The  symptoms  due  to  the 
various  localized  lesions  seen  in  these  infections  are  particularly 
dependent  upon  the  portal  of  entry,  and  are  often  so  marked  as  to 
obscure  the  general  nature  of  the  disease. 

The  most  common  mode  of  onset  is  seen  in  the  umbilical  infec- 
tions. There  is  a  rather  sudden  rise  of  temperature,  followed  by  an 
irregular  septic  fever.  The  temperature  curve  is  very  irregular  and 
can  only  be  properly  observed  by  a  four-hourly  chart.  At  some 
periods  of  the  day  it  may  be  very  high,  at  others  may  even  be  below 
normal.  After  a  period  of  such  fever,  the  temperature  in  some  cases 
may  remain  permanently  below  normal. 

Associated  with  fever,  the  two  most  common  symptoms  in  general 
sepsis  of  the  newborn  are  jaundice  and  hemorrhages.  Jaundice  is  an 
early  and  prominent  symptom,  but  is  not  always  present.  It  is  not 
of  the  complete  obstructive  type,  bile  being  found  in  the  stools,  as 
well  as  in  the  urine.  Purpura  is  the  most  common  hemorrhagic 
manifestation;  it  occurs  as  a  fine  petechial  rash,  or  as  large,  scattered, 


224  Diseases  OF  THE  Newborn 

dark-blue  blotches.  Hemorrhage  from  the  bowels  is  also  seen  at 
times,  and  more  rarely,  there  are  hemorrhages  from  the  nasal,  buccal, 
or  other  mucous  membranes. 

The  nervous  system  is  usually  profoundly  affected.  There  is  at 
first  a  notable  apathy,  which  rapidly  increases  into  stupor  leading 
to  complete  coma.  Prostration  is  very  marked,  and  a  condition  of 
extreme  exhaustion  is  apt  to  come  on  rather  rapidly.  In  other  cases, 
meningeal  symptoms,  such  as  restlessness,  irritability,  twitchings, 
spasm,  paralysis,  or  convulsions,  are  present. 

On  physical  examination,  the  liver  is  usually  found  enlarged.  One 
looks  for  localized  evidences  at  the  portal  of  entry,  which,  as  has 
been  already  stated,  often  cannot  be  found.  The  umbilicus  may  be 
inflamed,  the  umbilical  depression  may  be  filled  with  pus,  or  pus  may 
be  made  to  ooze  by  pressure  about  the  umbilicus.  There  may  be 
abdominal  distention  and  tenderness,  which  are  an  aid  to  the  diag- 
nosis in  umbilical  infections  where  the  umbilicus  appears  normal. 

On  the  skin,  or  on  the  mucous  membrane  of  the  mouth,  nose  or 
throat,  can  sometimes  be  observed  the  ulceration  or  abrasion  through 
which  the  infection  has  entered.  A  great  variety  of  lesions  may  be 
seen  in  these  situations. 

The  signs  of  localized  infection  are  sometimes  the  most  prominent 
clinical  manifestations  in  infectious  disease  of  the  newborn.  These 
signs  do  not  differ  essentially  from  those  of  the  same  lesion  when  not 
a  manifestation  of  this  particular  disease.  One  should  look  first 
for  signs  of  peritonitis;  then  for  signs  of  pneumonia,  pleuritis,  arth- 
ritis, osteomyelitis,  pericarditis,  meningitis,  and  encephalitis. 

DIAGNOSIS. — The  diagnosis  of  infectious  disease  of  the  new- 
born presents  extreme  difficulty,  owing  to  the  great  variety  of  the 
clinical  manifestations.  When  the  case  presents  the  clinical  syn- 
drome which  may  be  called  most  typical,  namely,  that  of  septic 
temperature  with  jaundice,  hemorrhages,  and  great  prostration,  the 
diagnosis  is  comparatively  easy.  The  other  causes  of  jaundice  in 
newborn  babies,  namely,  icterus  neonatorum,  and  congenital  cirrhosis 
of  the  liver,  are  not  associated  with  fever,  nor  do  they  show  extreme 
prostration.  Catarrhal  jaundice  often  is  associated  with  fever,  but 
is  very  rare  in  newborn  infants,  and  the  fever  is  not  of  a  septic  char- 
acter, nor  is  extreme  prostration  present.  The  other  causes  of 
hemorrhage  in  newborn  infants,  namely,  hemophiha  and  hemorrhagic 
disease  of  the  newborn,  can  usually  be  easily  excluded,  as  in  them 
hemorrhage  is  practically  the  only  symptom. 

The  most  difficult  cases  for  diagnosis  are  those  in  which  the  syn- 
drome described  above  is  not  present,  but  in  which  the  symptoms 
of  such  localized  lesions  as  peritonitis,  pneumonia,  meningitis,  or 
gastroenteritis   are   the  prominent   chnical   features.     It   should  be 


Ophthalmia  Neonatorum  225 

remembered  that  such  severe  symptoms  at  this  period  of  Hfe  are 
always  strongly  suggestive  of  a  general  sepsis. 

In  all  cases,  the  finding  of  evidences  of  infection  at  the  umbilicus, 
or  at  any  other  portal  of  entry,  is  a  great  aid  to  the  diagnosis. 

Laboratory  methods  are  not  of  much  aid.  The  blood  examina- 
tion usually  shows  a  marked  leucocytosis,  but  this  is  of  no  value 
in  recognizing  the  general  character  of  the  infection.  Only  by  blood 
culture  can  the  diagnosis  of  infectious  disease  of  the  newborn  be 
definitely  proven.  The  technic  of  blood  culture  in  newborn  infants 
is  so  difficult,  that,  while  it  has  been  successfully  done  in  hospitals, 
it  is  not  very  valuable  as  a  routine  method  of  diagnosis. 

PROGNOSIS.  The  prognosis  is  bad.  Nearly  all  the  severe  cases 
presenting  the  typical  syndrome  of  fever,  jaundice,  and  hemorrhage, 
die.  Death  may  occur  within  a  few  days,  or  may  be  postponed 
for  a  longer  period.  It  is  probable  that  nearly  all  cases  in  which 
there  is  a  general  sepsis,  or  any  important  visceral  lesion,  die  rapidly. 
A  few  cases  of  apparent  umbilical  infection  recover,but  it  is  probable 
that  in  these  cases  the  septic  process  never  became  general. 

PROPHYLAXIS.— That  infectious  disease  of  the  newborn  is  pre- 
ventable, is  shown  by  the  great  diminution  in  its  occurrence  in  insti- 
tutions since  the  introduction  of  aseptic  methods  into  obstetric  prac- 
tice. It  may  be  compared  to  puerperal  fever.  The  majority  of 
cases  are  caused  by  the  carelessness  of  some  attendant,  physician, 
nurse,  or  parent,  having  the  care  of  the  newborn  infant.  The  essen- 
tials are  cleanliness  of  the  child's  surroundings,  and  proper  care  of 
the  umbiHcus.  The  umbilicus  should  be  treated  like  any  clean, 
fresh  wound.  It  should  be  cleansed  and  dressed  with  sterile  dry 
dressings.  Everything  coming  in  contact  with  the  wound  should  be 
sterile.  Clean  clothes,  clean  hands,  and  clean  surroundings,  are  the 
other  essentials.  Care  should  be  taken  to  prevent  all  excoriation  or 
abrasion  of  the  skin  or  mucous  surfaces.  In  institutions  all  septic 
cases  should  be  strictly  isolated. 

TREATMENT. — The  treatment  is  purely  symptomatic.  When- 
ever any  locaHzed  focus  of  suppuration  open  to  surgical  treatment  is 
present,  incision,  evacuation,  and  drainage  should  be  performed. 
Vaccine  therapy  with  an  autogenous  vaccine  can  be  tried,  if  the 
microorganism  causing  the  disease  can  be  isolated  from  the  blood, 
or  from  a  localized  lesion.  There  are  as  yet  no  favorable  reports 
from  its  use,  and  I  do  not  think  it  offers  much  prospect  of  success. 

OPHTHALMIA  NEONATORUM 

Ophthalmia  neonatorum  is  an  inflammation  of  the  conjunctiva  of 
newborn  infants.     There  is  a  mild  catarrhal  form  occasionally  seen, 
which  is  caused  by  any  slight  irritation  of  the  eyes  of  the  infant. 
16 


226  Diseases  of  the  Newborn 

It  runs  a  very  mild  course,  attacks  chiefly  the  palpebral  conjunctiva, 
and  usually  the  only  symptoms  noted  are  a  slight  photophobia  and  a 
collection  of  secretion  in  the  angles  of  the  lids  and  upon  their  borders. 
The  usual  condition  known  as  ophthalmia  neonatorum  is  a  puru- 
lent conjunctivitis. 

ETIOLOGY. — The  gonococcus  is  the  most  frequent  pathogenic 
microorganism  in  this  disease.  A  few  cases  are  due  to  other  organ- 
isms, such  as  streptococci,  staphylococci,  and  pneumococci.  In- 
fection most  commonly  takes  place  during  birth  from  direct  contact 
of  the  conjunctiva  with  the  pus-forming  organisms  present  in  the 
vagina  of  the  mother,  who  has  a  vaginitis  due  to  gonococcus  or  other 
infection.  Occasionally  the  infection  may  be  carried  to  the  eyes  of 
the  infant  by  the  hands  of  the  physician  or  nurse,  or  by  contaminated 
linen  or  other  material,  and  in  such  cases  the  infection  may  take 
place  at  a  period  subsequent  to  birth. 

SYMPTOMS. — The  disease  begins  as  a  redness  of  the  conjunctiva, 
with  a  slight  discharge  from  the  corner  of  the  eye.  This  is  succeeded 
with  startling  rapidity  by  intense  inflammation  of  the  lids.  In 
twenty-four  hours  the  upper  lid  may  become  so  much  swollen  as  to 
overhang  the  cheek  and  render  opening  the  eye  impossible.  On 
separating  the  lids,  a  little  greenish  pus,  which  may  even  be  tinged 
with  blood,  wells  up  between  them.  At  first  the  cornea  is  unaffected, 
but  if  the  pus  accumulates  under  the  edematous  lids  it  soon  shows 
signs  of  ulceration.  In  the  second  twenty-four  hours  the  ulceration 
may  perforate  the  cornea  and  evacuate  the  aqueous  humor,  thus 
bringing  the  iris  into  contact  with  the  posterior  surface  of  the  cornea. 
The  swelling  may  extend  around  the  eye  and  well  over  the 
forehead  and  malar  prominence,  but  it  does  not  persist  in  the  latter 
region  very  long.  All  the  symptoms  disappear  slowly,  and  recovery 
takes  place,  except  in  those  cases  in  which  the  cornea  has  been  per- 
manently injured  by  ulceration. 

DIAGNOSIS. — The  diagnosis  of  purulent  ophthalmia  may  be 
easily  made  from  the  examination  of  the  eyes.  A  gonorrheal  etiology 
may  be  suspected  when  a  very  violent  inflammation  is  present,  and 
from  the  history  suggesting  gonorrheal  vaginitis  in  the  mother.  A 
positive  etiologic  diagnosis  can  be  made  only  by  bacteriological 
examination  of  the  purulent  discharge. 

PROGNOSIS. — The  earlier  the  pus  appears,  the  more  severe  will 
be  the  course  of  the  disease,  and  the  more  unfavorable  the  prognosis. 
Cases  seen  early  and  treated  properly,  terminate  as  a  rule  in  complete 
recovery.  Neglected  cases  and  very  severe  gonococcus  infections 
frequently  result  in  corneal  ulceration,  which  may  go  on  to  perfora- 
tion and  complete  loss  of  vision. 


Ophthalmia  Neonatorum  227 

TREATMENT. — Prophylaxis  is  the  most  important  part  of  the 
treatment  of  this  disease.  In  private  practice,  when  the  mother 
has  no  vaginal  discharge,  all  that  is  required  is  washing  the  eyes 
after  dehvery  with  a  weak  solution  of  boric  acid.  When  the  mother 
has  a  vaginal  discharge,  or  in  institutions,  Crede's  method  of  pro- 
phylaxis should  be  employed.  This  consists  in  dropping  one  or  two 
minims  of  a  two  per  cent,  solution  of  nitrate  of  silver  into  each  eye 
of  the  newborn  infant.  As  even  this  has  been  known  to  cause  a  con- 
siderable amount  of  irritation,  a  solution  of  protargol,  or  argyrol,  ten 
or  twenty  per  cent.,  is  often  used  in  preference  to  the  silver  nitrate. 

When  one  eye  only  has  become  infected,  care  must  be  taken  to 
prevent  the  spread  of  the  infection  to  the  other  eye.  This  is  accom- 
plished by  carefully  covering  the  sound  eye  with  cotton  and  a  bandage. 

After  the  disease  has  once  begun,  two  indications  must  be  kept  in 
mind:  (i)  To  reduce  the  inflammation,  and  (2)  to  prevent  the  pus 
from  accumulating  behind  the  tightly  closed  Hds.  By  far  the  best 
way  of  applying  cold  to  the  eye  is  by  compresses  of  soft  pieces  of 
linen  cut  into  small  squares.  Not  more  than  two  thicknesses  are 
to  be  used  at  once.  These  compresses  are  to  be  cooled  by  laying 
them  on  a  piece  of  ice  or  floating  them  in  ice  water.  They  must  be 
constantly  changed.  To  remove  the  pus,  a  gentle  irrigation,  such 
as  can  be  easily  obtained  by  using  a  medicine  dropper,  is  sufficient. 

In  the  irrigation  of  the  eye  one  should  first  turn  the  child's  head  a 
little  to  the  diseased  side,  and  with  the  fingers  of  the  left  hand  gently 
separate  the  lids  as  far  as  possible.  Then,  holding  the  dropper  with 
the  right  hand,  irrigate  between  the  lids,  directing  the  stream  from 
the  nose.  After  each  irrigation  vaseline  should  be  applied  to  the  edge 
of  the  lids.  This  should  be  done  at  least  every  half-hour,  day  and 
night,  until  the  swelling  has  so  far  subsided  as  to  preclude  the  danger 
of  any  secretion  being  retained.  For  irrigation  many  solutions  have 
been  advocated.  The  most  simple,  and  perhaps  the  best,  is  a  satu- 
rated solution  of  boracic  acid,  or  one  of  bichloride  of  mercury  in  the 
strength  of  0.05  gramme  (i  grain)  to  480  c.c.  (i  pint)  of  distilled, 
water.  In  addition  to  the  irrigations,  a  daily  instillation  of  a  2 
per  cent,  silver  nitrate  solution  should  be  used.  In  the  later  stages 
of  the  disease,  in  which  all  the  tissues  are  relaxed,  a  solution  of  nitrate 
of  silver,  or  still  better,  of  protargol  or  argyrol,  20  per  cent,  in  strength, 
painted  on  the  conjunctiva  with  a  camel's-hair  brush  once  daily,  is 
very  effective  in  shortening  the  course  of  the  disease. 

TETANUS  NEONATORUM 

This  disease  differs  in  no  way  from  tetanus  occurring  at  any  other 
period  of  hfe.  The  cause  is  the  same,  the  bacillus  of  tetanus,  which 
sometimes  finds  a  portal  of  entry  in  the  umbihcal  wound  of  new- 


228  Diseases  of  the  Newborn 

born  infants.  The  symptoms,  diagnosis,  and  treatment  differ  in  no 
essential  particular,  whether  the  disease  is  seen  in  the  newborn  or  at 
a  later  period  of  life. 

DERMATITIS  EXFOLIATIVA 

In  the  year  1878  Ritter  gave  the  first  complete  description  of  the 
disease  dermatitis  exfoliativa  neonatorum.  Previous  to  this  date  cases 
of  this  affection  had  been  reported,  but  many  of  them  were  regarded 
as  some  rare  or  unusual  manifestation  of  pemphigus.  Ritter  studied 
and  reported  the  cases  which  he  saw  at  the  Foundling  Asylum  in 
Prague  from  1868  to  1878.  A  careful  review  of  Ritter's  original 
observations  of  these  cases  has  been  made  by  Elliot.  The  majority 
of  cases  were  in  male  infants,  and  the  mortality  was  found  to  be 
48.82  per  cent.  The  disease  is  very  rare.  It  occurs  rarely  before 
the  end  of  the  first  week,  and  usually  appears  between  the  second 
and  the  fifth  week  of  life.  It  was  found  to  vary  greatly  in  the  in- 
tensity of  its  symptoms.  In  some  cases  a  dry  scaly  condition  of  the 
skin  preceded  the  subsequent  lesions,  which  had  apparently  lasted 
after  the  physiological  desquamation  of  the  epidermis  had  taken  place. 

SYMPTOMS. — The  first  symptom  noticeable  in  these  cases  was 
a  diffuse  redness,  usually  over  the  lower  half  of  the  face  about  the 
mouth,  sometimes,  however,  beginning  in  some  other  portion  of  the 
body,  and  at  times  being  universal  from  the  beginning.  This  hyper- 
emia of  the  skin  spread  rapidly,  and  in  a  few  days  became  universal, 
the  extremities,  as  a  rule,  being  the  last  parts  affected.  The  mucous 
membrane  of  the  mouth  and  the  nose  was  at  times  affected,  and  the 
conjunctivae  usually  participated  in  the  hyperemia.  The  color  of 
the  effiorescence  varied  from  a  light  to  a  dark  purple-red.  As  the 
hyperemia  extended  to  new  surfaces,  those  which  were  first  affected 
began  to  desquamate.  This  desquamation  at  times  gave  no  evidence 
of  exudation,  the  epidermis  being  simply  thickened,  and  the  loosened 
epithelium  separating  easily.  At  times  other  lesions  appeared,  such 
as  milia,  and  sometimes  the  horny  layer  of  the  skin  was  raised  above 
an  intensely  reddened  base,  and  large,  irregularly  shaped  bullae 
filled  with  fluid  were  formed.  After  the  desquamation  had  taken 
place  the  skin  recovered  its  normal  condition,  occasionally  very 
rapidly,  but  it  remained  for  some  time  rough  and  irritable.  In  the 
cases  in  which  there  was  no  exudation  a  longer  time  was  necessary 
for  the  separation  and  regeneration  of  the  epithelium. 

Usually  the  disease  was  found  to  run  its  course  in  from  seven  to 
ten  days.  Relapses  were  sometimes  observed  ten  or  twelve  days 
after  the  first  attack,  but  were  always  mild. 

In  typical  cases  the  process  was  unaccompanied  by  any  fever  or 
systemic    disturbances    unless     some     complication    existed.     The 


Infectious  Hemoglobinemia  229 

functions  were  normal,  and  the  weight  of  the  infant  remained  sta- 
tionary or  was  even  at  times  increased.  The  fatal  cases  resulted 
either  from  the  intensity  of  the  attack  or  from  some  intercurrent 
affection  or  sequela,  such  as  furunculosis.  This  disease  is  usually 
recognized  as  a  local  septic  infection  of  the  skin,  and  it  would  seem 
that  it  would  be  easily  distinguished  from  the  pemphigus  which 
occurs  in  the  early  weeks  of  life. 

INFECTIOUS  HEMOGLOBINEMIA  (Winkel's  Disease) 

Infectious  hemoglobinemia  is  an  affection  which  is  met  with 
in  newborn  infants,  usually  in  the  early  days  of  life,  and,  as  a  rule, 
arises  as  an  endemic  disease  in  hospitals.  The  disease  is  charac- 
terized by  extreme  cyanosis,  icterus,  hemoglobinuria,  somnolence, 
rapid  collapse,  and  the  absence  of  fever. 

ETIOLOGY. — The  etiology  of  this  disease  is  obscure.  A  specific 
microorganism  has  not  yet  been  discovered,  yet  the  endemic  char- 
acter of  the  malady  and  the  changes  which  are  produced  in  the  blood 
warrant  us  in  supposing  that  it  is  an  infectious  disease.  It  would 
be  described,  not  as  a  separate  infection,  but  as  a  probable  special 
manifestation  of  infectious  disease  of  the  newborn,  were  it  not  for 
its  epidemic  character,  which  suggests  a  probable  undescribed  specific 
infection  as  a  cause. 

PATHOLOGICAL  ANATOMY.— A  careful  post-mortem  examina- 
tion of  Winkel's  cases  showed  that  there  was  cyanosis  of  the  external 
and  internal  organs.  Except  in  one  instance,  no  pathological  condi- 
tion of  the  vessels  of  the  cord  was  described.  The  cortex  of  the 
kidney  was  found  to  be  wider  than  normal,  to  be  of  a  brownish  color, 
and  to  present  numerous  minute  hemorrhages.  In  some  places  the 
pyramids  were  entirely  black-red  in  color,  and  in  other  places  numer- 
ous black  streaks  were  found  which  converged  to  the  papillae.  This 
color  was  caused  by  the  filling  of  the  straight  tubules  with  granules 
of  hemoglobin.  Intact  erythrocytes  were  never  found.  The  blad- 
der was  found  to  contain  greenish-brown  urine.  The  spleen  was 
strikingly  enlarged  and  hard.  Its  length  was  about  7.5  cm.  (3  inches), 
and  its  weight  25  grammes  (5/6  ounce).  It  was  black-red  in  color, 
and  on  section  the  surface  was  smooth.  Microscopic  examination 
showed  a  considerable  accumulation  of  brownish  coloring  matter, 
partly  free  and  partly  in  the  pulp  cells. 

In  addition  to  these  appearances  in  special  organs,  minute  hemor- 
rhages were  found  in  nearly  all  the  organs,  but  especially  in  the 
pleura,  pericardium,  endocardium,  mucous  membranes  of  the  stom- 
ach and  small  intestine,  and  kidney;  they  were  also  found  in  the 
dura  and  pia  mater  and  under  the  capsule  of  the  liver.  The  lymph- 
follicles  were  swollen,  especially  Peyer's  patches  and  the  mesenteric 


230  Diseases  of  the  Newborn 

l3miph-glands.  A  microscopic  examination  showed  fatty  degenera- 
tion of  many  important  organs,  especially  the  liver,  and  at  times 
of  the  muscles  of  the  heart.  The  bacteriological  examinations  were, 
as  a  rule,  negative,  especially  as  regards  the  tissues  of  the  intestine. 
Clumps  of  bacteria  were  found  only  once  in  the  Hver  and  once  in 
the  kidney. 

SYMPTOMS. — The  first  s3maptoms  were  generally  restlessness  and 
cyanosis,  not  only  of  the  face  but  also  of  the  body  and  extremities, 
and  especially  of  the  back.  The  color  increased  progressively  until 
it  became  a  deep  blue.  To  this  was  added  an  icteric  color,  which 
when  death  did  not  occur  within  twenty-four  hours  became  very 
marked.  The  respiration  was  rapid;  the  pulse  was  not  especially 
increased  in  rate.  The  rectal  temperature  never  rose  higher  than 
38.1°  C.  (100.6°  F.).  The  skin  generally  felt  cool.  Vomiting  and 
diarrhea  occurred  in  some  cases.  The  most  striking  symptom  was 
the  appearance  of  the  urine.  It  had  a  pale  brownish  color,  and  was 
passed  frequently,  and  often  with  considerable  straining.  An  ex- 
amination showed  that  the  color  was  due  not  to  bile,  but  to  hemo- 
globin. In  the  sediment  were  found  numerous  epithelial  cells  from 
the  walls  of  the  kidney,  granular  casts  with  blood-corpuscles  adherent 
to  them,  micrococci,  masses  of  detritus,  and  urate  of  ammonia.  A 
small  quantity  of  albumin  was  present.  Later  in  the  disease  con- 
vulsions occurred,  followed  rapidly  by  death. 

In  other  cases  besides  those  of  Winckel's  in  which  the  blood  was 
examined  the  condition  was  found  to  be  one  of  hemoglobinemia. 
The  percentage  of  hemoglobin  was  high,  and  free  hemoglobin  was 
found  in  the  blood-serum,  while  the  erythrocytes  were  greatly  reduced 
in  number,  at  times  amounting  to  only  1,700,000  or  even  less. 

DIAGNOSIS. — The  resemblance  of  this  disease  to  the  form  of 
infectious  disease  known  as  acute  fatty  degeneration  of  the  new- 
born is  very  striking.  Most  of  the  symptoms  are  common  to  both 
diseases.  Large  hemorrhages  are  also  not  uncommon  in  this  dis- 
ease, but  are  not  so  marked  as  in  acute  fatty  degeneration.  The 
striking  points  of  difference  are  the  presence  of  hemoglobinuria  and 
the  fact  that  large  numbers  are  affected  at  the  same  time  in  in- 
fectious hemoglobinemia,  while  these  conditions  have  not  been  found 
in  acute  fatty  degeneration. 

TREATMENT.— The  treatment  should  be  the  administration  of 
oxygen  and  stimulants,  and  forced  feeding  by  means  of  a  dropper 
when  the  infant  is  too  weak  to  suck. 


VII.     PREMATURE  INFANTS 

APPEARANCE  AT  BIRTH.— The  picture  of  a  premature  infant 
in  the  early  days  of  Hfe  is  quite  characteristic.  Besides  its  very 
small  size,  as  shown  in  the  illustration,  where  the  size  is  compared 
with  the  nurse's  hand,  it  shows  in  varying  degrees  an  absence  of 
the  life  and  vigor  which  is  seen  in  the  fully  developed  infant  at  term. 
It  is  emaciated,  its  skin  being  soft,  wrinkled,  and  showing  very  little 
subcutaneous  fat.     Its  head  is  large,  its  abdomen  broad  and^dis- 

FlG.    67 


Infant  premature  at   seventh   month.     Birth-weight,    1740   grammes.     Age,   10   days; 

weight,  1540  grammes 

tended,  and  its  limbs  puny.  According  to  the  stage  of  its  develop- 
ment it  ma}^  or  may  not  have  the  remains  of  the  hair  (lanugo)  on 
its  body  which  was  present  in  uterine  life,  and  in  like  manner  its 
nails  may  or  may  not  be  well  formed.  Its  face  has  a  senile  expres- 
sion and  it  is  torpid  and  extremely  somnolent.  The  eyes  are  closed. 
Its  cry  is  very  feeble.  The  surface  temperature  is  usually  cool, 
the  extremities  seldom  move.  The  respirations  are  very  superficial 
and  irregular,  often  ceasing  altogether  for  a  few  seconds.  The  power 
to  suck  and  even  to  swallow  is  often  slight.  These  signs  evidently 
indicate  that  the  vitaHty  is  very  low,  and  if  the  weight  is  below  three 
or  four  pounds,  and  the  length  less  than  eighteen  or  nineteen  inches, 
that  the  functions  and  organs  are  not  developed  sufhciently  for 
use,  and  that  unless  unusual  care  be  taken  in  the  treatment  of  such 
cases,  they  will  soon  die. 

PROGNOSIS.— The  majority  of  infants  born  before  the  comple- 
tion of  the  seventh  month  of  pregnancy  die  within  a  very  short  time, 
although  I  have  seen  one  or  two  cases  of  survival  in  babies  premature 
in  the  sixth  month.     A  number  of  babies  premature  at  the  seventh 


232  Diseases  of  the  Newborn 

and  eighth  months  survive,  the  outcome  depending  on  the  vitaHty 
of  the  individual  baby,  and  the  care  with  which  it  is  treated.  There 
are  a  number  of  factors  which  make  the  prognosis  very  uncertain  in 
every  case.  Many  premature  infants  have  a  varying  degree  of 
congenital  pulmonary  atelectasis,  which  generally  lowers  their  vitaHty 
and  resistance.  SyphiKtic  infants  usually  die  within  a  few  days. 
Sclerema  is  a  very  unfavorable  sign.  The  best  prognostic  indica- 
tion in  a  premature  infant  is  the  temperature  curve.  If  with  arti- 
ficial heat  the  temperature  remains  subnormal,  or  if  the  curve  is 
very  irregular,  rising  above  the  normal  when  the  external  heat  is 
increased,  and  falling  below  the  normal  whenever  it  is  slightly  dimin- 
ished, the  probabihty  is  that  the  infant's  vitaHty  is  very  low.  When 
the  temperature  begins  to  approach  the  normal  line,  and  to  show  less 
irregularity,  the  prognosis  becomes  better.  The  weight  curve  stands 
next  to  the  temperature  curve  as  a  prognostic  sign.  A  steady  gain 
in  weight  is  a  very  favorable  sign.  Many  premature  infants,  how- 
ever, do  not  begin  to  gain  in  weight  for  a  number  of  weeks,  and 
yet  may  survive. 

It  must  be  remembered  that  even  with  the  best  care,  premature 
infants  are  Hable  to  sudden  death  from  no  apparent  cause.  This 
HabiHty  to  sudden  death  is  not  passed  when  the  infant  reaches  the 
period  of  fuU  term,  but  continues  for  a  number  of  months  thereafter. 

TREATMENT. — The  same  measures  of  care  which  are  indicated 
for  premature  infants,  are  also  appHcable  to  infants  who,  although 
born  at  full  term,  show  the  same  evidences  of  low  vitality  as  are 
characteristic  of  infants  prematurely  born. 

There  are  three  principal  points  to  be  considered  in  the  treatment 
of  premature  and  feeble  infants.  These  are  (i)  the  maintenance  of 
the  body  heat;  (2)  the  modifications  of  hygiene  and  care  which  are 
necessary  to  protect  the  infant  from  the  deleterious  influences  of 
the  external  world;  (3)  nourishment. 

Artificial  Heat. — For  the  maintenance  of  heat  in  premature 
infants,  various  forms  of  incubators  and  brooders  have  been  recom- 
mended and  widely  used.  My  experience  with  incubators  has  been 
entirely  unsatisfactory,  and  I  cannot  recommend  their  employment. 
An  "incubator  bed''  has  given  the  best  results  in  my  hands.  This 
consists  in  an  ordinary  infant's  crib,  padded,  and  with  the  lower 
half  covered  with  a  blanket,  sufficient  space  being  left  at  the  top 
for  the  admission  of  a  plentiful  supply  of  air. 

The  infant  is  wrapped  in  cotton.  The  best  means  of  wrapping 
the  infant  is  the  "premature  gown."  Such  a  gown  is  shown  in  the 
illustration.  It  is  made  of  a  thin  layer  of  absorbent  cotton,  about 
a  quarter  of  an  inch  thick,  between  two  double  layers  of  fine  gauze. 
The  layers  of  cotton  and  gauze  are  sewed  together  on  the  machine, 


Premature  Infants  233 

both  around  the  edges,  and  across  in  both  directions,  the  lines  of 
stitching  being  about  five  inches  apart.  The  dimensions  of  the  gown 
should  be  about  twenty-six  inches  in  length  by  twenty-three  inches 
in  width.  To  the  top  of  the  body  of  the  gown  is  attached  a  hood, 
made  of  the  same  materials.  The  infant  is  wrapped  in  this  gown, 
and  laid  in  the  incubator  bed. 

There  must  be  in  the  bed  with  the  infant  some  means  of  supplying 
artificial  heat.  An  excellent  device  for  this  purpose  is  an  electric 
pad  or  electrotherm.  Just  as  good  results  can,  however,  be  obtained 
by  the  use  of  hot  water  bottles.  Earthenware  bottles  filled  mth 
hot  water  and  wrapped  in  flannel  retain  their  heat  for  a  long  time. 
One  or  two  of  these  are  placed  in  the  bed  alongside  the  infant.  A 
thermometer  wrapped  in  absorbent  cotton  is  also  placed  in  the  bed 
beside  the  infant,  and  the  whole,  infant,  bottles,  and  thermometer, 
are  covered  with  a  blanket.  By  changing  the  water  in  the  bottles 
at  proper  intervals,  a  fairly  constant  temperature  can  be  main- 
tained in  the  incubator  bed.  Ordinarily  with  infants  of  fairly  good 
vitality,  the  thermometer  should  register  85°  to  95°  F.;  but  the  tem- 
perature which  is  maintained  in  the  incubator  bed  must  be  regulated 
by  the  rectal  temperature  curve  of  the  child.  If  this  shows  a  tendency 
to  remain  subnormal,  more  external  heat  will  be  necessary,  and  the 
temperature  of  the  bed  should  be  kept  at  from  95°  to  98°  F. 

Hygiene  and  Care. — The  premature  baby  must  have  a  constant 
supply  of  pure  fresh  air.  For  this  purpose,  the  infant  must  be  kept 
in  a  room  which  has  some  proper  communication  with  the  outdoor 
air,  the  temperature  of  the  room  being  maintained  by  ordinary 
heating  methods.  Under  ordinary  circumstances  the  temperature 
of  the  room  should  be  from  70°  to  72°  F. 

Most  pediatrists  believe  that  a  great  mistake  has  often  been  made 
in  having  the  air  of  the  room  too  warm.  Nevertheless,  I  find  that 
in  many  cases  a  warmer  temperature  is  of  distinct  value  provided 
that  the  air  is  kept  fresh.  When  a  premature  infant  in  a  properly 
devised  incubator  bed  and  in  a  room  of  72°  F.,  still  shows  a  tendency 
toward  constant  subnormal  temperature,  they  will  often  do  better 
if  the  temperature  of  the  room  be  kept  at  80°  F.  In  a  number  of 
cases  I  have  seen  premature  babies  who  had  not  been  gaining  in 
weight,  begin  to  gain  immediately  when  they  were  transferred  to  a 
room  at  80°  F.  The  probable  explanation  of  this  is  that  they  do 
not  have  to  use  so  much  of  their  nourishment  for  the  maintenance 
of  their  bodily  heat,  and  more  food  becomes  available  for  tissue 
building.  We  have  found  at  the  Infants'  Hospital  that  the  "80° 
room"  is  a  valuable  measure  in  the  treatment  of  certain  premature 
and  feeble  infants. 

The  premature  infant  should  be  handled  as  little  as  possible.     It 


234 


Diseases  of  the  Newborn 


should  not  be  bathed,  but  its  body  is  kept  oiled  with  olive  oil.  When 
it  is  necessary  to  change  the  diaper,  this  should  be  done  rapidly  and 
with  as  little  exposure  as  possible.  The  morning  and  evening  tem- 
peratures should  be  taken  daily,  as  this  record  is  necessary  in  regu- 
lating external  heat,  and  also  has  a  bearing  on  the  problem  of  nutri- 
tion. But  the  taking  of  the  temperature  should  be  attended  with  a 
minimum  of  handling  and  exposure.  The  premature  infant  should 
also  be  protected  from  excessive  light  and  from  noise. 

Fig.  71 


Feeder  for  premature  infants  (reduced  one-half) 


Feeding.— Breast  milk  should  be  used  in  the  nourishment  of 
premature  infants  whenever  possible.  Few  premature  infants  are 
strong  enough  to  take  the  breast.  In  the  early  weeks,  a  premature 
infant  should  be  fed  as  often  as  every  hour,  but  such  frequent  nurs- 
ing has  a  deleterious  effect  upon  the  secretion  of  the  mammary  glands 
of  the  mother  or  wet-nurse.  Consequently  the  infant  should  be  put 
to  the  breast  only  every  two  hours.  It  will  not  be  able  to  empty 
the  breast  and  the  remaining  milk  should  be  withdrawn  by  means 
of  the  breast  pump.     In  this  way,   sufficient  breast  milk  can  be 


Fig.  69 — Articles  for  premature  infant 


Premature  Infants  235 

obtained  for  use  in  the  alternate  feedijigs  when  the  infant  is  not  put 
to  the  breast.  When  an  infant  is  too  feeble  to  take  the  breast,  as 
is  usually  the  case  in  infants  born  before  the  eighth  month,  and  with 
feeble  babies  born  in  the  eighth  month,  the  infant's  food  can  be 
obtained  by  pumping  the  breasts  at  the  proper  intervals. 

The  method  of  administering  milk  to  a  premature  baby  who  is 
unable  to  take  the  breast  is  important.  If  the  infant  is  able  to  swal- 
low, the  milk  should  be  given  with  the  Breck  feeder.  This  consists 
in  a  graduated  glass  tube  narrowed  at  the  ends.  Over  one  end  is 
placed  a  proper  sized  nipple,  and  over  the  other  end  is  placed  a  rubber 
compression  bulb.  The  advantage  of  the  Breck  feeder  over  giving 
the  milk  with  a  spoon  or  medicine  dropper  is  that  the  sucking  reflex 
is  not  entirely  abolished.  There  is  evidence  that  the  sucking  reflex 
has  an  important  influence  upon  the  digestive  function,  and  with 
the  Breck  feeder,  even  though  the  baby  be  unable  to  suck  strongly 
enough  to  draw  the  milk  from  the  bottle,  it  can  make  efforts  at  suck- 
ing, and  can  be  helped  by  the  pressure  made  by  the  nurse  upon  the 
rubber  bulb.  Whenever  the  infant  is  so  feeble  that  it  is  unable  to 
swallow,  it  must  be  fed  by  means  of  gavage.  When,  as  often  hap- 
pens with  premature  infants,  the  mother  has  not  a  sufficient  supply 
of  milk,  a  wet-nurse  should  be  obtained  if  possible.  The  wet-nurse 
should  always  be  accompanied  by  her  own  infant,  and  should  nurse 
it,  as  the  requirements  of  the  premature  infant  will  not  be  suf- 
ficient to  maintain  the  normal  function  of  lactation  in  the  wet-nurse. 

The  quantity  to  be  given  at  a  feeding  to  premature  infants  varies 
with  the  age  and  weight  of  the  child.  With  a  seven  months'  baby 
weighing  from  three  to  four  pounds,  one  can  begin  with  half  an  ounce 
every  hour.  Changes  are  regulated  by  the  temperature  and  weight 
curves,  the  composition  of  the  food,  the  appearance  of  the  movements, 
etc.  Usually  after  a  few  weeks  the  amounts  can  be  increased  and 
the  intervals  made  longer,  so  that  the  baby  will  get  an  ounce  every 
two  hours.  This  amount  will  later  be  further  increased  in  accord- 
ance with  the  ordinary  principles  of  infant  feeding. 

When  a  wet-nurse  cannot  be  obtained,  artificial  feeding  becomes 
necessary.  It  is  true  that  the  outlook  with  artificial  feeding  is  not 
so  good  as  it  is  with  human  milk,  but  the  prognosis  is  not  so  bad 
as  some  writers  would  lead  one  to  suppose.  In  all  premature  infants 
we  have  to  contend  only  with  congenital  weakness  of  the  digestive 
powers,  and  such  cases  are  often  not  so  difficult  to  manage  with  arti- 
ficial feeding  as  are  older  infants  whose  powers  have  been  ruined  by 
improper  feeding. 

The  amount  to  be  given  at  a  feeding  and  the  intervals  between 
feedings  are  the  same  with  artificial  feeding  as  when  breast  milk  is 
used.  The  composition  of  the  food,  however,  must  be  weak.  In 
my  experience  premature  infants  have  less  difficulty  in  digesting 


236  Diseases  of  the  Newborn 

the  fat  than  the  casein  of  cow's  milk,  fat  indigestion  being  a  partic- 
ular manifestation  of  infants  who  have  been  improperly  fed.  Conse- 
quently, I  usually  select  for  a  premature  infant  a  whey  mixture  or 
split  protein  formula.     An  average  food  to  begin  with  is — 

Fat,  i;  lactose,  5;  whey  protein,  0.75;  casein,  0.25;  lime  water, 
20  per  cent,  of  the  milk  and  cream. 

The  methods  of  obtaining  such  a  food  are  described  in  the  division 
on  Feeding.  Further  changes  in  the  composition  of  the  food  will 
depend  upon  the  weight  curve  and  symptoms  of  the  infant,  the 
physician  being  guided  by  the  general  principles  of  infant  feeding. 

The  signs  of  insufficient  nourishment  in  a  premature  infant  are, 
failure  to  gain  in  weight,  constipation,  but  otherwise  good  stools, 
and  a  persistent  tendency  toward  subnormal  temperature.  The 
signs  that  the  food  is  too  strong,  or  improperly  adjusted  to  the  diges- 
tive power  of  the  infant,  are,  vomiting,  green  or  undigested  move- 
ments, and  failure  to  gain  in  weight. 


•i\: 


m 


Fig.  70 — Premature  infant  in  bed 


Premature  Infants 

Chart  4 


237 


/\rAJ\r^\ 


Chart  of  feeble  infant  no^  premature,  showing  the  effect  of  the  premature  gownZaftd 

incubator  bed 

The  feeding  was  not  changed  during  the  period  represented  by  this  chart,  which  shows 
the  temperature,  pulse,  respiration,  and  weight  curves. 

A.  Infant  admitted  to  hospital  and  placed  in  ordinary  bed. 

B.  Infant  placed  in  incubator  bed  and  premature  gown. 

C.  Infant  taken  out  of  incubator  bed  and  premature  gown. 
W.  Weight  curve. 

It  will  be  noted  that  under  ordinary  treatment  the  temperature  remained  subnormal 
and  there  was  a  steady  loss  of  weight.  When  no  other  change  in  the  treatment  than 
putting  the  baby  into  the  incubator  bed  and  premature  gown  was  made,  the  tempera- 
ture rose  at  once  to  the  normal,  and  gain  in  weight  was  rapid.  Later,  when  removed 
from  the  incubator  bed,  the  infant  maintained  a  normal  weight  but  did  not  gain  so  rapidly. 
The  artificial  heat  of  the  incubator  bed  enabled  this  infant  to  spare  food  from  heat  pro- 
duction and  from  the  effort  to  maintain  a  normal  temperature,  and  to  utilize  this  food  for 
tissue  building. 


238 


Diseases  of  the  Newborn 

Chart  5 


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41  6 
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40  3 
40  0 
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37  7 
37  8 

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Chart  of  premature  infant,  showing  temperature,  pulse,  respiration,  and  weight  curves 

A.  Treatment  begun. 

W.  Weight  curve. 

It  is  to  be  noted  that  at  the  beginning  of  treatment  the  temperature  was  subnormal, 
but  the  infant  did  well  and  steadily  gained  in  weight.  As  improvement  occurred,  the 
temperature  rose  to  the  normal  line. 


DIVISION  IV 

FEEDING 

I.     GENERAL  PRINCIPLES 

Just  as  the  highest  aim  of  medical  art  should  be  directed  to  the 
province  of  preventive  medicine,  so  the  highest  and  most  practical 
branch  of  preventive  medicine  should  consist  of  the  study  of  the 
best  means  for  starting  young  human  beings  in  Ufe.  They  should 
be  preserved  from  the  perils  which  surround  the  early  hours  of  their 
existence,  and  be  given  strength  and  vigor  to  resist  the  attacks  which 
must  inevitably  be  made  on  their  vitahty,  which  are  greater  and 
more  dangerous  in  inverse  proportion  to  their  age.  With  these  objects 
in  view,  the  preventive  medicine  of  early  life  becomes  pre-eminently 
the  intelHgent  management  of  the  nutriment  which  enables  young 
human  beings  to  breathe  and  grow  and  live.  In  fact,  it  is  a  proper 
or  an  improper  nutriment  which  makes  or  mars  the  perfection  of  the 
coming  generations.  The  feeding  of  infants  is,  then,  the  subject  of 
all  others  which  should  interest  and  incite  to  research  all  who  are 
working  in  the  domain  of  pediatrics,  and  in  fact  as  a  matter  of  public 
health,  a  practical  knowledge  of  the  modern  methods  of  infant  feeding 
becomes  an  imperative  duty.  The  subject  is  a  great  one,  and  is 
worthy  of  the  most  careful  study.  It  should  be  taken  up  carefully. 
It  should  be  dealt  with  broadly. 

In  re\iewing  the  immense  amount  of  literature  which  has  accumu- 
lated on  the  subject  of  feeding,  we  find  that  the  superiority  of  human 
milk  to  all  other  kinds  of  infant  food  in  the  early  months  of  life  is 
acknowledged  so  generally,  that  it  has  become  an  axiom.  On  the 
other  hand,  the  opinions  expressed  regarding  artificial  feeding  in  the 
past  are  so  diverse  and  so  opposed  to  one  another  that  it  is  evident 
that  much  which  has  in  former  years  been  taught  must  be  unlearned, 
or  rather  admitted  to  be  untrue,  before  we  can  expect  to  make  any 
decided  progress  in  this  most  difficult  subject. 

The  feeding  problem  is  one  which  is  surrounded  with  many  difficul- 
ties on  account  of  the  great  diversity  of  individual  circumstances  and 
idiosyncrasies.  Certain  infants  thrive  on  pecuHar  mixtures  which 
are  not  adapted  to  infants  as  a  class.  Many  will  not  thrive  on  that 
food  which  nature  has  provided  for  them,  and  the  well-being  of  an 
infant  will  depend  much  upon  the  circumstances  by  which  it  is  sur- 
rounded, such  as  affluence  or  poverty,  country  or  city  life.     The 


240  Feeding 

constituents  of  the  nutriment  which  nature  has  provided  for  the 
offspring  of  all  mammals  in  the  early  period  of  their  existence  is  essen- 
tially animal  and  never  vegetable.  It  is  therefore  evident  that  an 
animal  food,  entirely  and  freshly  derived  from  animal  and  not  vegeta- 
ble sources,  has  been  proved  to  be  the  nutriment  on  which  the  greatest 
number  of  human  beings  live  and  the  least  number  die. 

THE  MAMMARY  GLAND.— The  mammary  gland,  in  its  perfect 
state,  uninfluenced  by  disease  or  nervous  disturbance,  or  by  the 
improper  living  of  the  mother,  is  a  beautifully  adapted  piece  of  mechan- 
ism constructed  for  the  elaboration  and  secretion  of  an  animal  food. 
When  in  equilibrium  it  represents  the  highest  type  of  a  living  machine 
adapted  for  a  special  purpose, — mechanically,  physiologically,  and 
economically.  The  breasts  of  all  mammals  are  elaborators  and  pro- 
ducers. They  are  not  storehouses  for  preserving  sustenance  until 
it  is  needed.  They  are  dehcately  constructed  mills,  turning  out 
when  demand  is  made  for  it,  a  product  which  has  been  directly 
formed  within  their  walls  from  material  which  has  been  brought 
through  their  portals  from  various  parts  of  the  economy.  The  breast 
is  a  compound  racemose  gland,  lined  with  glandular  epithelium, 
which  forms  sugar,  fats,  and  proteids,  and  these  are  mixed  with  water 
from  the  blood.  The  epithelial  cells  are  so  finely  organized,  and  so 
sensitive  with  their  minute  nerve  connections,  that  changes  of  atmos- 
phere, changes  in  food,  the  emotions,  fatigue,  sickness,  the  catamenia, 
pregnancy,  and  many  other  influences,  throw  their  mechanism  out 
of  equilibrium  most  readily,  and  change  essentially  the  proportions 
of  their  finished  product.  Then  again  this  delicate  mechanism 
adapts  itself  to  the  quantity  of  its  product,  elaborating  a  smaller  or 
a  greater  supply,  according  to  the  demand  actually  made  upon  it 
by  the  consumer.  The  same  breast  will  either  supply  the  proper 
amount  of  milk  demanded  for  the  requirements  of  the  average  age 
or  a  greater  amount  for  the  same  age  in  case  of  a  greater  gastric  capac- 
ity. Again,  this  machinery  is  regulated  as  to  the  time  which  it  takes 
to  produce  the  average  food  required  for  the  different  ages,  a  shorter 
interval  of  feeding  being  needed  for  the  younger  infant  and  a  longer 
one  for  the  older.  This  fact  is  made  evident  by  the  decided  quahta- 
tive  changes  which  result  when  the  gland  is  called  upon  to  produce 
its  product  at  improper  intervals.  Moreover,  the  product  of  the 
mammary  gland  is  clean,  free  from  injurious  bacteria,  and  is  already 
warmed  to  the  proper  temperature  demanded  by  the  delicate  mouth 
and  stomach  of  the  young  infant.  The  analyses  of  large  numbers 
of  specimens  of  human  milk  at  different  periods  of  lactation  show  us 
that  not  only  do  the  constituents  vary  from  month  to  month,  and 
even  from  day  to  day,  but  that  this  variation  takes  place  as  much 
in  the  early  as  in  the  later  periods  of  lactation.     We  are  not  war- 


General  Principles  241 

ranted,  therefore,  in  assuming  that  the  milk  grows  stronger  as  its  age 
increases,  provided  that  it  still  remains  in  normal  equilibrium.  The 
mammary  gland  acts  both  as  a  secretory  and  as  an  excretory  organ, 
so  that  it  cannot  be  classed  as  a  metabolic  tissue  in  the  limited  mean- 
ing which  we  now  attach  to  these  words.  Yet  the  metabolic  phe- 
nomena giving  rise  to  the  secretion  of  milk  are  so  marked,  so  distinct, 
and  have  so  many  analogies  with  the  metabolism  which  we  meet  in 
adipose  tissue,  that  we  must  look  upon  the  mamma  chiefly  as  a 
secretory  organ  (Foster).  This,  however,  is  only  within  certain 
limits,  for  we  know  that  at  times  foreign  elements  may  be  excreted 
from  the  gland.  This  at  once  suggests  the  interesting  question  as 
to  when  the  mammary  gland  is  most  likely  to  have  what  we  might 
call  its  normal  secretory  function  interfered  with  and  to  assume 
temporarily  the  function  of  an  excretory  organ.  This  seems  to 
occur  both  before  the  gland  has  attained  its  equipoise,  as  during  the 
colostrum  period,  and  later  when  any  of  the  above-mentioned  influ- 
ences occur  which  affect  the  general  mechanism  of  the  gland.  In 
these  instances  we  find  the  colostrum  reappearing  in  the  milk. 
Therefore  in  the  beginning  of  lactation,  during  lactation  when  normal 
metaboHsm  is  interfered  with,  and  as  lactation  draws  to  a  close,  we 
have  analogous  conditions  in  which  the  mammary  gland  instead  of 
being  a  normal  secretory  organ  becomes  abnormal  and  more  or  less 
an  excretory  organ.  During  these  periods  of  abnormal  gland  excre- 
tion we  must  remember  that  drugs  can  be  eliminated  by  the  milk 
more  freely  than  when  the  gland  is  in  equipoise.  We  assume,  there- 
fore, that  the  mamma  during  that  early  period  of  lactation,  which 
essentially  represents  a  condition  of  lack  of  equipoise,  has  a  double 
function,  partly  secretory,  partly  excretory.  The  greater  the  excre- 
tory function  of  the  gland  is  at  any  time  in  proportion  to  the  secre- 
tory, the  more  abnormal  will  be  the  finished  product;  while  the  nearer 
the  gland  approaches  to  a  purely  secretory  organ,  the  more  perfect 
and  normal  will  be  its  product.  The  mechanism  of  the  mammary 
gland  is  therefore  in  its  most  perfect  condition  after  the  colostrum 
period  has  ceased,  and  at  a  time  when  the  general  organism,  both 
physical  and  mental,  is  freed  from  causes  detrimental  to  a  perfect 
metabolism. 

General  principles  are  vital  in  their  importance  when  we  come  to 
study  the  subject  of  feeding  in  all  its  phases,  whether  the  nutriment 
to  be  provided  for  the  infant  is  to  come  directly  from  its  mother,  a 
wet-nurse,  or  an  animal,  or  indirectly  from  the  product  of  the  mam- 
mary gland.  These  principles  are,  (i)  That  nature  throughout  all 
ages  has  clearly  indicated  by  means  of  natural  selection  what  the 
source  of  supply  should  be;  that  is,  that  the  mother  should  during 
some  early  period  of  its  life  supply  food  for  her  offspring  from  her 
mammary  glands.  (2)  That  when,  owing  to  disease,  over-civiUza- 
16 


242  Feeding 

tion,  or  any  causes  which  prevent  the  offspring  from  receiving  its 
sustenance  directly  from  the  maternal  mammae,  some  nutriment 
must  be  substituted  which  will  correspond  as  closely  as  possible  to 
the  natural  food-supply.  (3)  That  this  substitution  can  be  obtained 
most  exactly  through  the  product  of  the  mammary  gland  of  another 
woman.  (4)  That,  owing  to  the  strong  analogy  between  human 
beings  and  all  animals  which  suckle  their  young,  we  should  in  our 
efforts  to  copy  good  human  milk  make  use  not  only  of  what  we  have 
learned  from  human  beings,  but  also  of  what  is  known  of  lactation  as 
it  occurs  in  animals.  This  requires  a  knowledge  of  the  investigations 
and  experience  of  those  who  have  studied  commercially  the  breed- 
ing of  animals  and  their  food,  and  the  production  and  modification 
of  their  milk. 


II.     MATERNAL  FEEDING 

Human  milk  is  the  only  ideal  food  for  infants.  The  statistical 
results  of  breast  feeding  are  vastly  superior  to  those  of  artificial  feed- 
ing. In  Berlin,  in  the  years  from  1900  to  1904  only  9  per  cent  of  the 
infant  mortality  occurred  in  breast-fed  infants.  In  Boston,  statistics 
show  that  an  artificially  fed  infant  is  six  times  as  likely  to  die  than 
is  a  breast-fed  infant. 

In  spite  of  these  facts,  we  frequently  encounter  mothers  who  prefer 
not  to  nurse  their  infants.  They  give  as  a  reason  that  the  study  of 
artificial  feeding  has  led  to  such  perfecting  of  the  methods  employed, 
that  the  best  artificial  feeding  directed  by  the  most  carefully  trained 
physicians  gives  results  sufficiently  good  to  make  this  a  safe  method. 
These  same  mothers,  in  rearing  their  children,  would  hesitate  to  vio- 
late any  other  hygienic  principle,  when  such  violation  would  diminish 
six-fold  the  chance  of  their  child  surviving.  Only  gross  ignorance 
of  the  facts  can  explain  their  desire  to  incur  such  a  risk.  It  is  the 
duty  of  every  physician  to  impress  the  superiority  of  maternal  feeding 
upon  every  mother,  and  to  steadfastly  refuse  to  countenance  any  other 
method  of  feeding  unless  absolutely  necessary.  The  desire  of  the 
mother  to  be  relieved  of  the  trouble  and  confinement  incidental  to 
nursing,  is  not  a  sufficient  reason  for  resorting  to  the  bottle. 

If  human  milk  is  the  ideal  infant  food,  a  thorough  knowledge  of 
all  its  characteristics  is  essential  to  the  study  of  infant  feeding. 

HUMAN  MILK 

PHYSICAL  CHARACTERISTICS.— Human  milk  is  of  a  bluish- 
white  color  and  closely  resembles  cow's  milk  in  appearance.  It  is 
odorless  and  has  a  somewhat  sweeter  taste  than  has  cow's  milk.  The 
specific  gravity  averages  betv/een  1.030  and  1.032,  the  extreme  varia- 
tions being  1.020  and  1.038.  The  reaction  is  amphoteric,  alkaline  to 
litmus,  and  sHghtly  acid  to  phenolphthalein.  Microscopically  are 
seen  many  minute  fat  droplets  of  an  almost  uniform  size.  Human 
milk  shows  a  coagulation  when  acids  are  added.  With  the  rennin 
ferment  no  change  is  observed  until  the  milk  is  acidified,  although 
the  ultramicroscope  shows  that  the  rennin  acts  in  neutral  solutions. 
Human  milk  does  not  coagulate  uniformly  with  rennin,  and  the  casein 
is  precipitated  with  greater  difficulty  with  acids  than  is  the  case  with 
cow's  milk.  The  diminished  coagulability  of  human  milk  has  been 
explained  by  the  relative  alkalinity  of  the  milk  and  by  its  low  calcium 
content.  The  curd  formed  is  very  fine  and  often  can  only  be  seen 
with  the  microscope. 


244  Feeding 

CHEMICAL  COMPOSITION.— Milk  contains  fat,  carbohydrate, 
and  protein  substances,  together  with  certain  mineral  salts  and  water. 
A  large  number  of  analyses  gives  the  following  composition  for  an 
average  human  milk: 

Table  i8 

Average  Human  Milk 

Fat 3      to    4      per  cent 

Carbohydrate 6      to    7      per  cent 

Protein i      to    2      per  cent 

Ash 0.2  per  cent 

Water 86.8  to  89.9  per  cent 

The  fat  in  human  milk  is  in  the  form  of  minute  globules,  which  are 
held  in  a  permanent  emulsion  by  the  fluid  in  which  they  are  suspended. 
The  fat  is  made  up  chiefly  of  the  nonvolatile  fatty  acids,  palmitic, 
stearic,  myristic,  and  oleic  acids.  Among  these  oleic  acid  predom- 
inates. The  volatile  fatty  acids  are  present  in  small  quantities  in 
human  milk,  constituting  no  more  than  about  2  per  cent  of  the  total 
fat.  Among  them  have  been  demonstrated  butyric,  capronic,  ca- 
prinic,  and  caprylic  acids. 

The  carbohydrate  of  human  milk  is  lactose,  or  milk-sugar.  It  is 
in  solution. 

The  protein  of  human  milk  is  of  two  chief  forms,  one  of  which  is 
soluble  in  water,  the  other  insoluble.  The  insoluble  protein  is  casein, 
and  is  held  in  suspension  in  milk,  probably  because  it  is.  in  chemical 
combination  with  the  calcium  phosphate.  The  soluble  proteins  con- 
sist of  a  number  of  substances,  of  which  the  predominating  is  lactal- 
bumin.  A  globuhn  is  also  found,  and  possibly  other  nitrogenous 
substances.  Lactalbumin  much  resembles  the  serum  albumin  of  the 
blood. 

Analyses  differ  widely  as  to  the  relative  proportions  of  soluble  pro- 
tein and  casein  in  human  milk,  Konig,  in  a  total  protein  of  1.82  per 
cent  estimated  casein  at  0.59  per  cent,  and  the  soluble  protein  at  1.23 
per  cent.  The  figures  now  most  generally  adopted  are  those  of 
Schlossmann,  who  found  that  about  41  per  cent  of  the  total  nitrogen 
in  human  milk  is  in  the  form  of  casein.  There  is  in  milk,  however, 
a  certain  amount  of  so-called  residual  nitrogen  contained  in  bodies 
which  are  not  protein,  such  as,  possibly,  urea.  This  may  be  from  15 
to  20  per  cent,  and  if  it  is  deducted,  only  44  to  39  per  cent  is  left  for 
the  soluble  proteins.  It  is  easiest  to  remember  that  in  human  milk 
the  casein  and  soluble  proteins  are  in  about  equal  proportion.  The 
composition  of  the  mineral  salts  in  human  milk  is  not  thoroughly 
known.  Analyses  differ  widely  and  variations  are  great.  The  table 
shows  some  analyses  from  various  observers: 


Human  Milk 


245 


Table  19 

Percentage  of  Salts  in  Human  Milk  to  100  Parts  of  Ash 

(From  Engell  and  Schloss) 


BLACKHAND 

AND 
KRONHEIM 


SCHXOSS 


I 

K20 32  .  14 

Na2o 11-75 

Cao 15.67 

Mgo 3.99 

Fe203 0.27 

P205 21 .42 

CL 20.35 


I 

33-34 
II  .91 
17.36 

3-17 

0.63 

14.79 

15-47 


II 

27-33 
15-88 

15-52 
2.13 

1-75 
11-75 
23-93 


19.9 
29.6 
12.9 
2.9 
0.25 
17.9 
21.3 


28.77 

10.26 

20.44 

4.66 

22.0 
16.61 


Gradually  importance  has  been  attached  to  the  ferments  or  enzymes 
of  milk,  especially  in  the  discussion  as  to  whether  raw  or  boiled  milk 
is  most  favorable  to  the  metabolism  of  the  infant.  All  that  can  be 
said  at  present  is  that  a  large  number  of  such  ferments  have  been  found 
in  human  milk,  such  as  proteolytic,  fat-splitting,  and  carbohydrate- 
splitting  ferments,  pepsin,  trypsin,  fibrinogen,  and  a  number  of  others. 
The  role  of  these  ferments  is  still  unknown. 

VARIATIONS  IN  MILK.— The  composition  of  human  milk  is  by 
no  means  constant.  Not  only  do  the  milks  of  different  women  differ 
widely  from  one  another,  but  the  milks  of  an  individual  woman  vary 
from  day  to  day,  and  even  from  hour  to  hour.  The  composition  of 
the  milk  obtained  at  the  beginning,  at  the  middle,  and  at  the  end  of 
a  nursing  shows  considerable  variation.  The  percentage  of  fat,  for 
example,  increases  steadily  from  the  beginning  to  the  end  of  each 
nursing. 

The  normal  variation  in  the  milks  of  different  women,  or  in  the 
milk  of  the  same  woman  at  different  times,  is  most  marked  in  the  fat. 
Extreme  variations  in  the  fat  are  from  o.i  per  cent  to  13.7  per  cent. 
Normal  variations  are  from  2  per  cent  fo  6  per  cent.  The  sugar 
varies  least,  extreme  variation  being  from  4.22  per  cent  to  10.9  per 
cent,  and  normal  variation  being  from  6  per  cent  to  7  per  cent.  The 
protein  shows  a  gradual,  but  rather  marked  increase  during  lacta- 
tion. Its  normal  variations  are  i  to  2  per  cent,  and  extreme  varia^ 
tion  from  0.2  to  3.4  per  cent. 

It  does  not  follow  from  the  fact  of  these  variations  in  the  composi- 
tion of  human  milk,  that  a  departure  from  the  standard  of  an  average 
milk  is  a  cause  of  harm,  or  an  explanation  of  any  symptoms  of  dis- 
turbance which  may  be  present.  Variation  is  the  normal  condition, 
and  the  composition  of  an  average  milk  does  not  constitute  a  standard 
of  excellence  in  this  ideal  baby  food.  We  should  rather  conclude 
that  nature  provides  these  variations  for  a  purpose,  to  meet  varia- 


246  Feeding 

tions  in  the  digestive  powers  and  requirements  of  different  babies. 
In  attempting  to  make  an  artificial  food,  we  should  remember  that 
variation  is  an  essential  feature,  and  that  babies,  in  general  cannot 
be  fed  on  an  arbitrary  food  of  fixed  composition. 

COLOSTRUM. — The  most  marked  variation  in  the  milk  is  seen 
in  the  earUest  days  of  the  infant's  Ufe.  When  the  secretion  of  the 
mammary  glands  first  begins,  the  milk  differs  widely  from  that  seen 
when  lactation  has  become  fully  established.  The  milk  secreted  at 
this  time  is  called  colostrum,  and  it  has  a  less  sweet  taste  than  the 
later  milk,  and  is  of  a  deeper  yellow  color.  The  color  was  formerly 
supposed  to  be  due  to  the  presence  of  colostrum  corpuscles,  but  is 
attributed  by  Czerny  to  a  coloring  matter  contained  in  the  fat 
drops.  Colostrum  is  coagulated  into  solid  masses  by  heat.  The 
specific  gravity  ranges  from  1.028  to  1.072,  the  average  being  about 
1.040.  In  reaction  it  is  strongly  alkaline.  The  chemical  composi- 
tion of  colostrum  differs  markedly  from  that  of  the  later  milk.  The 
analyses  to  be  found  in  the  Hterature  of  the  subject  differ  very  widely, 
and  many  of  them  are  probably  based  on  rather  faulty  chemistry. 
The  analysis  most  frequently  given  in  textbooks  is  based  on  the  aver- 
age of  five  analyses  by  Pf eiff er,  and  is  as  follows : 

Table  20 

Composition  of  Colostrum 

Fat 2 .  04  per  cent 

Lactose 3-74  per  cent 

Protein 5 .  71  per  cent 

Salts 0.28  per  cent 

Water 88 .  23  per  cent 

Microscopically  the  fat  droplets  in  colostrum  are  more  unequal  in 
size  than  in  ordinary  milk.  There  are  in  addition  certain  bodies 
known  as  colostrum  corpuscles,  which  are  large,  round,  and  granular, 
with  a  nucleus.  They  are  j?l:obably  leucocytes,  whose  cell  membranes 
are  completely  filled  with  small  fat  drops.  They  persist  in  milk  for 
a  week  or  ten  days,  gradually  disappearing. 

The  most  recent  theory  on  colostrum  is  that  advanced  by  Czerny 
and  Keller.  According  to  their  view,  if  the  infant  does  not  empty 
the  breasts  and  they  fill  up  again  with  secretion,  there  is  a  change 
in  the  composition  of  the  milk  as  the  result  of  absorption  of  its  dif- 
ferent components.  This  changed  secretion  they  designate  as  colos- 
trum, and  explain  its  presence  in  the  breasts  during  pregnancy  and 
the  first  few  days  postpartum  by  the  fact  that  the  breast  is  at  this 
time  not  completely  emptied,  and  that  re-absorption  takes  place.  Under 
this  theory  they  also  include  as  colostrum  all  milk  in  which  there 
has  been  any  absorption  such  as  would  appear  when  the  mammary 
secretion  is  in  process  of  drying  up,  or  when  a  feeble  infant  is  unable 


Human  Milk 

Fig.  72 


247 


Colostrum  milk  from  cow.     (Photo-micrograph.) 


Colostrum  milk  from  woman.     (Photo-micrograph) 


248 


Feeding 


properly  to  empty  the  breast.  It  has  been  observed  that  the  colos- 
trum corpuscles  always  reappear  in  the  milk  when  nursing  is  stopped 
and  the  milk  is  drying  up,  and  that  they  are  seen  even  when  lactation 
is  interrupted  for  a  few  days. 

DAILY  QUANTITY  OF  HUMAN  MILK.— The  quantity  of 
secretion  produced  by  the  breast  during  the  first  days  of  Hfe  is  very 
small.  On  the  first  day  the  quantity  of  colostrum  secreted  is  only 
from  10  to  20  c.c,  and  on  the  second  day  from  80  to  100  c.c.  The 
quantity  of  milk  secreted  daily  after  lactation  has  become  estabHshed, 
varies  within  the  widest  limits.  It  is  measured  by  weighing  the  baby 
before  and  after  each  nursing.  The  quantity  differs  in  the  case  of 
each  individual  woman,  and  differs  in  the  same  woman  at  the  different 
periods  of  lactation.  The  quantity  also  varies  with  the  weight, 
vigor,  and  demands  of  the  baby.  In  view  of  this  variability,  it  would 
seem  as  if  any  figures  showing  the  average  quantity  taken  by  normal 
babies  from  the  breast  at  different  times,  would  have  comparatively 
Httle  practical  value.  Unfortunately,  this  is  the  only  method  we 
have  of  arriving  at  any  idea  as  to  how  much  food  the  normal  baby 
should  take  each  twenty-four  hours,  and  such  a  standard  is  necessary 
both  in  judging  disturbances  of  breast  feeding,  and  in  planning  a 
routine  of  artificial  feeding.  It  has  been  shown  that  the  quantity 
taken  from  the  breast  by  normal  infants  is  a  better  guide  to  their  food 
requirements,  than  are  post-mortem  measurements  of  gastric  capacity. 

The  table  taken  from  Czerny  and  Keller  gives  Feer's  calculation 
of  daily  quantity  for  babies  of  average  weight  (Camerer's  figures). 

Table  21 

Average  Daily  Amount  of  Milk  Drawn  by  a  Baby 

(From  Czerny  and  Keller) 


AVERAGE 

AVERAGE 

WEIGHT  OF 

THE 

WEIGHT   OF 

THE 

AGE 

BREAST-FED 

CALCULATED 

AGE 

BREAST-FED 

CALCULATED 

IN 

BABIES 

day's  amount 

IN 

BABIES 

day's  amount 

WEEKS 

ACCORDING  TO 
CAMERER, 

OF  MILK, 

WEEKS 

ACCORDING   TO 
CAMERER, 

OF  MILK, 

GM. 

GM. 

GM. 

GM. 

I 

3,410 

291 

14 

5,745 

870 

2 

3,550 

549 

15 

5,950 

878, 

3 

3,690 

590 

16 

6,150 

893 

4 

3,980 

652 

17 

6,350 

902 

5 

4,115 

687 

18 

6,405 

911 

6 

4,260 

736 

19 

6,570 

928 

7 

4,495 

785 

20 

6,740 

947 

8 

4,68s 

804 

21 

6,885 

956 

9 

4,915 

81S 

22 

7,000 

958 

10 

5,055 

800 

23 

7,150 

970 

II 

5,285 

808 

24 

7,285 

980 

12 

5,455 

828 

25 

7,40s 

990 

1.3 

5,615 

852 

26 

7,500 

1,000 

Human  Milk  249 

BACTERIOLOGY. — Human  milk  is  generally  considered  to  be 
sterile,  but  investigations  have  shown  that  the  milks  of  healthy  women 
contain  bacteria  in  the  majority  of  instances.  The  organism  most 
commonly  found  is  the  staphylococcus  aureus,  but  others  may  be 
present.  They  are  generally  believed  to  enter  the  ducts  from  with- 
out. Under  normal  conditions,  these  organisms  have  no  pathological 
significance  for  the  healthy  infant. 

CONDITIONS  AFFECTING  LACTATION.— It  has  generally 
been  held  that  the  composition  of  the  milk  of  a  nursing  mother  is  and 
can  be  much  influenced  by  her  diet.  Much  investigation  has  failed 
to  reveal  any  very  direct  or  important  influence  exercised  upon  the 
milk  by  the  nurse's  diet.  It  has  been  shown  that  the  quantity  of 
fat  will  diminish  when  nursing  women  are  underfed,  and  will  increase 
to  some  extent  when  more  fat  is  given  in  the  diet.  Certain  fruits  and 
vegetables  eaten  by  the  mother  occasionally  produce  a  sudden  dis- 
turbance of  digestion  in  nursing  babies.  Such  disturbances  are  how- 
ever, an  idiosyncrasy,  and  do  not  come  under  any  general  rule.  The 
weight  of  modern  opinion  grants  little  influence  to  diet. 

That  certain  drugs  taken  by  the  mother  can  be  excreted  in  the 
milk  has  been  definitely  proven.  Drugs  known  to  have  been  so  ex- 
creted, are,  according  to  Talbot,  potassium  iodid,  sodium  sahcylate, 
antipyrin,  mercury,  aspirin,  calomel,  arsenic,  bromides,  hexamethy- 
lenamin,  and  bodies  soluble  in  fat.  These  drugs,  however,  are  found 
in  milk  only  in  slight  traces,  and  probably  cannot  do  harm,  except  in 
the  case  of  salvarsan,  when  sudden  death  of  the  infant  has  occurred 
after  treatment  of  the  mother.  Alcohol  is  found  in  breast  milk  only  in 
minimal  amounts,  and  only  after  a  very  large  quantity  has  been  taken. 

Vegetable  poisons,  and  toxins  formed  in  the  mother,  may  be  passed 
into  the  milk.  Antibodies  may  go  over,  and  it  has  been  shown  that 
immunity  can  be  transmitted  to  the  infant  through  the  breast  milk. 
This  probably  explains  the  immunity  against  infection  possessed 
by  the  nursing  baby,  not  seen  in  bottle  fed  babies.  Much  work  is 
now  being  done  on  the  transmission  of  various  immune  bodies. 

Nervous  impressions. — Excessive  nervous  disturbance,  excitement, 
or  violent  emotions  may  produce  a  marked  alteration  in  the  composi- 
tion of  milk.  The  evidence  of  this  phenomenon  is  mainly  rather 
clinical  than  chemical,  but  there  is  some  evidence  that  such  nervous 
disturbance  causes  an  actual  chemical  change,  the  protein  becoming 
increased,  through  which  the  baby  becomes  ill. 

Menstruation  usually  produces  Httle  chemical  change.  Some 
cases  have  been  reported  of  marked  change  in  the  composition  of 
breast  milk  during  menstruation.  The  coming  on  of  menstruation, 
is  not  a  sign  that  a  baby  should  be  weaned  because  of  this  cause 
alone.    Pregnancy,  however,  is  a  contraindication  to  nursing. 


250  •  Feeding 

MATERNAL  NURSING 

NORMAL  MATERNAL  CONDITIONS.— The  assumption  that 
the  maternal  is,  when  normal,  the  ideal  source  of  infant  food-supply 
presupposes  many  important  conditions  concerning  the  mother  and 
the  function  of  her  mammary  glands.  She  should  be  strong  and 
healthy,  of  an  even,  happy  temperament,  desirous  of  nursing  her 
infant,  and  have  time  to  devote  herself  to  this  special  duty  during 
the  whole  period  of  her  lactation.  She  should  have  a  sufficient  supply 
of  milk,  and  should  be  wilHng  to  regulate  her  diet,  her  exercise  and 
her  sleep  according  to  the  rules  which  will  best  fit  her  for  her  task. 
These  may  be  said  to  be  the  ideal  conditions  which  we  endeavor  to 
obtain  for  an  infant  which  is  to  be  nursed  under  the  most  favorable 
circumstances.  Because  these  ideal  conditions  cannot  always  be 
obtained  does  not  mean  that  maternal  nursing  is  not  the  best  method 
of  feeding  the  baby.  When  the  failure  of  ideal  conditions  is  due  to 
such  facts  as  that  the  mother  is  unhappy,  has  an  uncontrollable  tem- 
perament, is  unwilling  to  nurse  her  infant,  is  hurried  in  the  details 
of  her  life,  is  irregular  in  her  diet  and  in  her  periods  of  rest  and  exercise, 
it  does  not  necessarily  follow  that  breast  feeding  will  be  a  failure,  or 
that  the  mother's  breast  milk  will  not  be  a  better  food  for  her  baby 
than  any  artificial  food.  Under  such  circumstances  breast  feeding 
is  not  likely  to  be  so  successful  as  under  the  ideal  conditions  described, 
but  nevertheless,  it  should  always  be  tried,  while  every  effort  is  made 
to  remove,  improve,  or  correct  unfavorable  features.  At  the  outset, 
breast  feeding  should  always  be  tried,  unless  the  mother  has  abso- 
lutely no  milk,  or  unless  some  positive  contraindication  for  breast 
feeding  exists. 

CONTRAINDICATIONS  FOR  BREAST  FEEDING.— The  only 
positive  contraindications  for  breast  feeding  are  the  following:  i. 
Tuberculosis  of  any  form  in  the  mother.  2.  Epilepsy  or  insanity  in 
the  mother.  3.  When  the  mother  is  very  dehcate  and  feeble,  or  is 
suffering  from  any  serious  chronic  disease.  4.  When  the  mother's 
pregnancy  and  labor  have  been  attended  by  any  serious  compHca- 
tions,  such  as  sepsis,  hemorrhage,  nephritis,  or  eclampsia.  S3qDhilis 
is  not  a  contraindication  for  the  mother  to  nurse  her  own  baby,  but 
obviously  should  preclude  her  nursing  any  other  baby. 

SUCKING. — The  natural  method  of  feeding  is  by  sucking.  The 
infant  should  be  placed  in  a  comfortable  position  in  its  mother's  arms, 
with  its  head  and  back  supported.  It  should  be  made  at  once  to 
understand  that  it  is  to  begin  its  meal  as  soon  as  the  breast  is  offered 
to  it,  and  continue,  of  course  with  breathing-spells,  until  the  meal 
is  finished.  The  mother  should  herself  preferably  be  sitting,  as  she 
can  thus  best  manage  and  control  the  infant  if  it  is  inchned  to  be 
restless. 


Maternal  Nursing 


251 


Sometimes  babies  are  unable  to  nurse  in  the  natural  manner  by 
sucking.  Such  inabihty  of  the  infant  to  nurse  may  be  caused  by  a 
condition  on  the  part  of  the  mother,  in  which  the  nipples  are  very 
small  or  depressed.  Nipple  shields  will  sometimes  obviate  the  diffi- 
culty; when  this  device  is  employed,  great  care  must  be  exercised  in 
keeping  clean  the  glass  shield  and  rubber  nipple.  Inability  to  nurse 
may  be  due  to  certain  conditions  on  the  part  of  the  infant,  such  as 
deformities  of  the  sucking  mechanism,  great  feebleness,  or  premature 
birth.  In  such  a  case,  the  breast  pump  should  be  employed  to  obtain 
the  breast  milk  which  the  baby  needs.  Under  the  use  of  the  breast 
pump,  the  secretion  of  the  breasts  is  liable  to  diminish,  and  eventu- 
ally to  disappear.  Sometimes  it  is  well,  if  possible,  to  borrow  a 
strong,  healthy  baby,  to  empty  the  breast  once  or  twice  a  day. 


Fig.  73 

'k 

\ 

Nc 

Breast-pump 

The  breast  pump  is  an  apparatus  for  obtaining  milk  by  suction. 
A  number  of  such  devices  are  sold,  but  none  is  absolutely  satisfactory. 
The  main  essential  is  to  have  a  device  which  is  easily  kept  clean. 

CARE  OF  THE  BREASTS.— The  care  of  the  breasts,  if  free  from 
fissures  and  excoriations,  requires  nothing  more  than  scrupulous 
cleanliness.  They  should  be  bathed  before  and  after  nursing  with 
cold  water  which  has  been  boiled.  A  piece  of  folded  sterile  Unen  or 
some  other  soft  sterile  absorbent  material  should  be  kept  on  the 


252  Feeding 

nipples  to  protect  them  from  contact  with  the  clothing  and  to  absorb 
any  overflow  from  the  breasts. 

When  the  nipples  are  very  tender  and  cause  great  discomfort  to 
the  mother  during  the  nursing,  their  condition  frequently  becomes 
so  serious  an  obstacle  as  to  prevent  nursing  altogether.  Any  change, 
however,  should  not  be  thought  of  for  at  least  several  days,  or  until 
it  is  absolutely  certain  that  the  exquisite  pain  is  more  than  the  mother 
is  willing  or  able  to  endure.  It  is  often  the  case  that  after  a  brief 
continuation  of  great  suffering  from  tender  or  excoriated  nipples  the 
whole  difficulty  will  pass  away  and  the  mother  be  able  to  nurse  her 
infant  with  comfort.  Fissures  of  moderate  severity  should  be  treated 
by  washing  with  sterile  water  after  the  nursing,  and  by  applying 
boracic  acid  ointment,  or  the  compound  tincture  of  benzoin.  In 
more  severe  cases  nitrate  of  silver  should  be  applied  to  the  fissures, 
the  healthy  skin  being  protected.  Care  should  be  taken  not  to  apply 
remedies  which  might  injure  the  infant.  Where  the  nipples  show  a 
tendency  to  be  dry  and  hard,  it  is  well  to  apply  some  simple  ointment 
once  or  twice  a  day  during  the  last  few  weeks  of  the  pregnancy.  As- 
tringents, as  a  rule,  should  not  be  used.  Bathing  with  cold  water 
before  and  after  the  nursing,  and  thus  keeping  the  tissues  in  a  healthy 
condition,  is  a  valuable  prophylactic  measure. 

Another  trouble  which  may  arise  during  the  nursing  period  is  a 
disturbance  of  the  mammary  gland  itself,  sometimes  amounting 
merely  to  a  stasis  in  its  milk  production,  but  again  going  on  to  in- 
flammation. The  latter  is  a  serious  matter,  and  should  at  once  be 
placed  in  the  hands  of  a  skilful  surgeon.  The  former  condition  re- 
quires great  care  in  its  management.  Gentle  massage  from  the 
periphery  of  the  gland  towards  the  nipple,  amounting  in  fact  to 
merely  a  dehcate  stroking  with  the  ends  of  the  fingers,  is  an  important 
part  of  the  treatment.  The  breast  should  be  withheld  from  the 
infant  for  about  twenty-four  hours,  and  the  milk  from  time  to  time 
drawn  in  small  quantities  by  means  of  a  properly  adjusted  breast- 
pump.  The  breast  should  also  be  carefully  supported  by  a  swathe. 
If  these  measures  are  begun  as  soon  as  there  are  any  indications  of 
disturbance  in  the  breast,  these  abnormal  conditions  soon  disappear. 
The  indications  referred  to  consist  in  the  appearance  of  hard  swell- 
ings in  place  of  the  usual  soft  elastic  condition  of  the  milk  glands. 
These  swelHngs  may  occur  without  any  especial  pain,  but  on  palpa- 
tion they  are  usually  tender  to  a  greater  or  less  degree. 

When  nursing  must  be  temporarily  interrupted  on  account  of 
tender  or  excoriated  nipples,  the  breast  pump  is  indicated,  or  the 
nipple  shield  may  first  be  tried. 

NURSING  IN  THE  NEWBORN.— The  newborn  baby  should  be 
put  to  the  breast  at  the  end  of  six  to  twelve  hours,  and  ever>^  six 


Maternal  Nursing  253 

hours  for  the  next  twenty-four  hours.  After  this  period  it  should 
nurse  every  four  hours  for  another  twenty-four  hours,  and  then 
should  begin  the  regular  routine  which  is  to  be  followed  throughout 
early  infancy.  The  infant  will  obtain  very  little  food  during  the 
first  two  days  of  its  life,  as  the  secretion  of  the  breast  is  not  yet  estab- 
lished. The  object  of  putting  the  infant  regularly  to  the  breast  in 
these  early  days,  is  to  stimulate  the  breast  secretion.  The  sucking 
of  a  normal  infant  is  the  best  possible  stimulus  to  the  flow  of  milk. 

The  infant  does  not  need  more  food  in  these  early  hours  of  its  life. 
If  there  were  such  a  need,  Nature  would  supply  it.  It  is  not  neces- 
sary nor  wise  to  give  an  infant  sugar  solution,  nor  artificial  food  during 
the  first  forty-eight  hours.  It  does  need  water  to  flush  out  the  kid- 
neys, and  one  or  two  teaspoonfuls  may  be  given  every  two  hours. 
Most  babies  do  not  begin  to  show  signs  of  hunger  till  after  forty-eight 
hours,  and  at  this  time  the  breast  secretion  usually  begins  to  be  more 
profuse.  If  there  is  still  delay,  and  very  little  milk  in  the  breast, 
the  bottle  must  be  used  temporarily,  but  every  eft"ort  should  still  be 
made  to  encourage  the  mammary  secretion,  by  putting  the  baby  to 
the  breast  at  proper  intervals,  and  letting  him  get  what  he  can  by 
sucking.  In  the  bottle  feedings,  care  must  be  taken  to  give  neither 
too  much  nor  too  rich  food.  The  artificial  food  should  be  made  very 
weak,  and  its  strength  should  be  increased  slowly  if  the  baby  digests 
it  well.  A  whey  mixture  is  preferable  for  these  early  feedings.  Two 
drachms  may  be  given  at  first,  at  two-hour  intervals,  and  this  amount 
is  increased  if  the  baby  is  not  satisfied. 

Colostrum  is  supposed  to  have  a  laxative  effect.  If  the  bowels 
have  not  moved  at  all  at  the  end  of  twenty-four  hours,  one  teaspoonful 
of  castor  oil  should  be  given. 

MANAGEMENT  OF  NORMAL  NURSING.— The  great  essen- 
tial in  the  management  of  breast  feeding,  is  to  insure  the  most  abso- 
lute regularity  of  the  nursing.  This  must  not  only  be  recommended 
by  the  physician,  but  enforced.  Infants  rapidly  tend  to  form  habits, 
and  when  they  are  fed  regularly,  they  soon  get  into  the  habit  of 
expecting  their  feedings  at  regular  times.  They  will  then  sleep  more, 
and  will  only  cry  and  show  signs  of  hunger  when  their  feeding  is  due. 
This  gives  the  mother  more  peace,  enables  her  to  plan  her  work  better, 
and  under  such  happy  conditions,  she  is  free  from  nervous  anxiety, 
and  the  quality  of  her  milk  remains  good.  Irregularity  in  nursing 
is  the  most  common  cause  of  disturbance  in  the  quality  of  human 
milk.  Such  change  in  the  milk  tends  to  produce  a  greater  or  less 
degree  of  indigestion  on  the  part  of  the  baby.  Mothers  should  be 
instructed  not  to  nurse  the  baby  before  its  regular  feeding  time  comes 
due,  even  if  it  cries  and  seems  hungry.     On  the  other  hand  they  must 


254 


Feeding 


be  told  to  wake  the  baby  up  if  it  happens  to  be  asleep  at  nursing  time. 
Under  such  management  the  baby  soon  acquires  regular  habits. 

The  Intervals  Between  Feedings. — These  are  less  important 
than  regularity,  provided  they  be  not  too  short.  There  is  consider- 
able difference  in  opinion  and  practice  in  different  parts  of  the  coun- 
try as  to  what  the  nursing  intervals  should  be.  The  tendency  in 
some  locaHties  is  to  use  longer  intervals,  such  as  four  hours.  The 
clinical  evidence  brought  -forward  in  favor  of  long  intervals  is  not 
very  conclusive,  nor  is  there  evidence  based  on  accurate  scientific 
investigation  of  the  emptjing  time  of  the  stomach.  Infants  can  be 
accustomed  to  longer  intervals,  but  the  process  of  training  them  is 
often  troublesome,  and  there  is  no  proved  advantage  to  be  gained.  I 
beHeve  the  tendency  toward  long  intervals,  under  present  e\ddence, 
is  rather  a  fad  than  a  practice  to  be  recommended.  Indi\adual 
variation  also  plays  a  part,  some  babies  doing  better  on  longer,  and 
others  on  shorter  intervals.  The  intervals  which  I  am  accustomed 
to  recommend  are  the  following: 


Table  22 
Intervals  Between  Feedings 


AGE 

NUIIBER  OF 

FEEDIXGS IN 

24  HOTRS 

NIGHT 
FEEDINGS 

INTERVALS 

First  4  weeks                       

10 

or       8 

8 
or       7 

7 
6 

6 

or       5 

I 
I 

I 
I 

I 

0 

0 
0 

2    hours 

4  weeks  to  3  months 

2I  hours 
2I  hours 

3  to  6  months 

3    hours 
3    hours 

6  to  9  months 

3    hours 

Q  to  12  months               

3    hours 

3  or  4  hours 

The  feedings,  exclusive  of  the  night  feeding,  are  supposed  to  begin 
at  6  A.  M.  and  end  at  9  or  10  p.  M.  By  night  feedings  are  meant  feed- 
ings given  between  9  or  10  p.  m.  and  6  a.  m.  This  is  the  only  feeding 
at  which  an  absolutel}-  regular  hour  is  not  essential,  but  which  can 
be  given  when  the  baby  wakes  up  and  cries.  If  however,  the  baby 
wakes  up  and  cries  a  second  time  in  the  night,  it  is  better  to  give  the 
night  feeding  at  a  regular  time  in  the  middle  of  the  period,  about  2 
A.  M.,  in  order  that  the  baby  shall  not  form  the  habit  of  wanting  more 
than  one  night  feeding.  The  figures  showing  night  feedings  in  the 
table  represent  the  maximum.  Generally,  the  night  feeding  should 
be  dropped  as  soon  as  possible  at  any  age,  and  as  soon  as  the  baby 


Maternal  Nursing  255 

iDegins  to  sleep  through  the  night  until  within  one  or  two  hours  of 
his  morning  feeding,  he  should  be  accustomed  to  go  the  whole  time 
without  a  night  feeding.  As  a  baby  grows  older,  the  last  day  feeding, 
■or  evening  feeding,  should  also  be  dropped  as  soon  as  possible. 

An  alternative  between  shorter  and  longer  intervals  is  given  at 
some  ages  in  the  table.  When  a  baby  has  been  pre\dously  accustomed 
to  shorter  intervals,  the  shorter  alternative  should  be  used  first,  and 
then  later  the  longer  alternative  should  be  substituted.  With  a  baby 
pre\dously  accustomed  to  longer  intervals,  or  who  is  under  your  care 
from  the  time  of  its  birth,  the  longer  intervals  may  be  used  from  the 
start. 

The  baby  should  be  nursed  on  alternate  breasts  at  each  nursing, 
if  the  mother  has  plenty  of  milk.  If  there  is  any  tendency  to  de- 
ficiency of  milk  supply,  both  breasts  should  be  used  at  every  feeding 
after  the  first  two  morning  feedings.  The  baby  should  not  nurse 
more  than  twenty  minutes;  if  he  takes  longer,  it  is  a  sign  that  some- 
thing is  wrong.  On  the  other  hand,  if  he  takes  his  full  supply  in  less 
than  fifteen  minutes,  he  should  be  made  to  take  longer  breathing 
spells.  A  baby  gets  half  his  meal  in  the  first  five  minutes,  and  one- 
quarter  more  in  the  next  five  minutes.  He  should  not  go  to  sleep 
while  nursing;  if  he  does,  it  generally  means  that  the  baby  is  feeble, 
or  that  there  is  too  little  milk. 

HYGIENE  OF  THE  NURSING  MOTHER.— The  essentials  in 
the  hygiene  of  the  nursing  mother  are,  freedom  from  nervous  excite- 
ment and  worry,  regular  habits  of  life,  plenty  of  sleep,  a  proper  die-, 
and  sufficient  exercise. 

The  diet  of  the  nursing  mother  should  not  essentially  differ  from 
■what  would  be  considered  to  be  a  suitable  one  for  her  at  any  time. 
There  is  no  special  diet  which,  under  all  circumstances,  is  best  for  all 
nursing  women  during  the  period  of  their  lactation.  In  the  early 
days  of  the  puerperium  there  is,  as  a  rule,  more  danger  of  overfeeding 
than  of  underfeeding  the  mother.  A  light  and  plentiful  diet  should 
be  given  to  the  mother  while  she  is  confined  to  her  bed.  This  diet 
should  consist  of  milk,  gruels,  soups,  vegetables,  bread  and  butter, 
and  after  the  first  week  a  small  amount  of  meat  once  during  the  twenty- 
four  hours.  When  the  mother  is  able  to  go  out  of  the  house  again, 
and  has  resumed  her  usual  habits,  the  quality  of  the  diet  can  be  very 
much  increased,  and  she  can  have  the  usual  variety  of  food  repre- 
sented by  meats,  vegetables,  milk,  fruits,  and  cereals.  There  are  no 
special  kinds  of  food  which  are  contraindicated,  provided  that  the 
food  be  kept  within  the  Hmits  of  the  ordinary  articles  which  commonly 
represent  a  plain  but  nutritious  diet.  It  is  very  important  for  the 
nursing  mother  to  have  her  meals  at  regular  intervals,  and  during  the 
early  part  of  the  lactation  to  take  food  somewhat  more  frequently 


256  Feeding 

than  when  she  is  not  nursing.  The  additional  meals,  as  a  rule,  should 
be  made  up  of  milk  or  cocoa.  There  does  not  seem  to  be  any  advan- 
tage in  adding  any  special  beverages,  such  as  beer,  malt,  or  stimulants, 
to  her  diet.  She  should  receive  as  much  milk  as  is  compatible  with 
her  digestion,  and  should  drink  a  plentiful  supply  before  retiring  at 
night.  Certain  vegetables,  and  sometimes  fish,  will  in  individual 
cases  affect  the  milk  and  cause  discomfort  to  the  infant.  We  must, 
then,  in  every  case,  seek  to  determine  which  article  of  diet  may  cause 
disturbance  in  the  special  woman's  milk  secretion,  and  eliminate  that 
article.  We  should,  however,  be  very  careful  not  to  exclude  this 
special  article  of  diet  from  the  regimen  of  a  large  number  of  women 
to  whom  it  might  be  of  benefit  rather  than  of  harm,  simply  because  it 
has  affected  the  milk  of  a  few  women.  For  the  average  woman  a  plain 
mixed  diet,  with  a  moderate  excess  of  fluids  and  proteids  over  what 
she  is  normally  accustomed  to,  will,  as  a  rule,  give  the  best  results. 

Exercise  has  so  constant  an  influence  on  the  changes  which  take 
place  in  the  daily  secretion  of  the  milk,  that  the  mother  should  be 
encouraged  to  be  out  of  bed  and  to  walk  about  her  room  as  soon  after 
her  confinement  as  is  possible  without  injuring  her  physical  condi- 
tion. Exercise  is  so  important  for  promoting  the  proper  elaboration 
and  equilibrium  of  the  milk  secretion  during  the  entire  period  of 
lactation,  that  it  should  always  be  insisted  upon,  and  regular  hours 
for  walking  should  be  as  definitely  arranged  during  the  day  as  the 
hours  for  eating.  The  exercise  must,  however,  be  in  accordance  with 
the  strength  of  the  special  woman,  for  fatigue  has  the-  same  delete- 
rious influence  on  the  production  of  the  milk  as  has  lack  of  exercise. 

EVIDENCES  OF  NORMAL  LACTATION.— In  judging  of  the 
results  of  breast  feeding  in  any  given  case,  we  must  fully  appreciate 
the  fact  that  it  is  the  equilibrium  between  the  digestion  and  nutrition 
which  constitutes  success.  A  child  may  digest  its  milk  perfectly 
and  yet  drop  steadily  behind  in  its  weight  development.  On  the 
other  hand,  it  may  make  satisfactory  gains  in  weight  from  week  to 
week,  in  spite  of  persistent  symptoms  of  gastric  and  intestinal  indi- 
gestion. In  either  case  the  indications  for  regulation  of  the  feeding 
are  present. 

It  is  desirable  to  keep  careful  records  of  the  state  of  the  digestion, 
and  of  the  weekly  gains  in  weight.  A  child  in  whom  the  equilibrium 
between  digestion  and  assimilation  is  well  established  shows  the 
unmistakable  signs  of  good  health.  It  is  free  from  vomiting  and 
colic.  Its  sleep  is  restful  and  regular.  It  is  always  eager  to  nurse 
and  is  satisfied  at  the  end  of  the  prescribed  period  of  fifteen  or  twenty 
minutes.  It  cries  only  when  disturbed  by  urination,  defecation,  or 
hunger  shortly  before  nursing.  The  movements  are  regular,  one  or 
two  a  day,  smooth,  of  a  Hght-yellow  color  and  mush-like  consistency 


Disturbances  of  Breast  Feeding  257 

and  slight  sour,  but  not  foul  or  fecal  odor.  Its  weekly  gain  in  weight 
is  regular  but  varies  greatly,  according  to  individual  peculiarity.  The 
importance  of  weight  development  as  an  indication  of  the  nutrition 
of  the  infant  is  very  great  and  furnishes  us,  both  in  breast  and  sub- 
stitute feeding,  with  the  most  valuable  evidence  of  all  as  to  the  success 
of  the  feeding  in  any  particular  case. 

DISTURBANCES  OF  BREAST  FEEDING 

CAUSES. — In  all  disturbances  of  nutrition  in  infancy  there  is  one 
factor  which  is  constantly  present.  This  is  the  relatively  undeveloped 
digestive  mechanism  of  the  young  infant.  The  degree  to  which  the 
digestive  power  is  undeveloped  is  not  fixed  and  constant  in  all  babies 
of  the  same  age,  but  varies  in  different  individual  babies.  This 
variation  in  digestive  power,  and  in  food  requirement,  is  so  constant, 
that  it  may  be  considered  normal. 

Disturbance  of  digestion  and  nutrition  is  due  to  lack  of  balance 
between  the  digestive  power  and  requirement  of  the  individual  baby, 
and  the  food  which  is  given  to  that  baby.  The  two  factors,  peculiar- 
ity of  digestive  power  on  the  part  of  the  baby,  and  unsuitable  compo- 
sition on  the  part  of  the  food,  combine  to  produce  the  disturbance. 

In  the  majority  of  normal  breast-fed  babies,  the  first  factor  plays 
very  little  part.  The  digestive  mechanism  of  the  baby,  though  un- 
developed as  compared  with  that  of  older  children,  is  nevertheless 
fitted  to  digest  human  milk,  and  will  digest  human  milk,  unless  for 
some  reason  the  milk  is  particularly  unsuitable  in  composition.  Ba- 
bies are  seen  at  times,  however,  who  fail  to  digest  the  mother's  milk, 
even  when  the  chemical  composition  of  their  food  shows  no  wide 
variation  from  the  normal  average.  In  such  babies  we  must  assume 
that  individual  peculiarity  of  digestive  power  plays  a  considerable 
part.  Such  babies  will  usually  digest  human  milk  better  than  any 
artificial  food.  Only  in  very  rare  instances  are  babies  seen  who  will 
digest  a  cow's  milk  modification  better  than  human  milk.  Even  in 
cases  where  the  mother's  milk  does  show  a  considerable  variation 
from  the  normal  average,  individual  peculiarity  of  digestive  power 
may  play  a  part,  and  the  milk  may  be  well  digested  by  another  baby. 

It  is  best  to  regard  this  factor  of  individual  variation  in  digestive 
power  as  constant  and  normal,  and  when  disturbance  of  breast  feeding 
is  seen,  to  attribute  such  disturbance  to  unsuitable  milk.  As  there 
is  no  constant  standard  for  breast  milk  composition,  our  conclusion, 
in  disturbance  of  breast  feeding,  is  that  this  particular  milk  is  not 
wholly  suited  to  the  digestion  of  this  particular  baby. 

In  seeking  the  cause  of  disturbed  breast  feeding,  we  must  look  for 
all  the  causes  which  may  produce  an  unsuitable  breast  milk. 

The  violation  of  any  of  the  requisites  for  normal  lactation  outlined 
17 


258  Feeding 

above  may  be  the  cause.  The  commonest  is  irregular  habits  of  nurs- 
ing. Worry,  nervousness,  excitement,  overeating,  constipation,  in- 
sufficient sleep,  insufficient  exercise,  menstruation,  pregnancy,  acute 
illness — any  of  these  may  be  the  cause.  In  many  cases  the  cause 
cannot  be  found;  the  milk  is  or  becomes  either  insufficient  in  quantity 
or  quality,  or  abnormal  in  quality,  without  any  apparent  reason.  In 
such  cases,  the  cause  is  to  be  sought  in  heredity,  and  in  the  condi- 
tions of  the  life  of  our  present  civilization. 

Several  t\pes  of  abnormal  breast  milk  are  particularly  common. 
Perhaps  the  commonest  is  an  over-rich  milk,  high  in  all  the  nutritive 
elements,  having  a  composition  of  fat  5  or  6  per  cent,  sugar  8  per  cent, 
protein  2  1/2  or  3  per  cent.  Such  a  milk  is  often  seen  in  well-fed 
women  who  take  insufficient  exercise.  Another  t}^e  of  abnormal 
breast  milk  is  low  in  fat  and  sugar,  high  in  protein,  having  a  composi- 
tion of  approximately  fat  2  per  cent,  sugar  5  or  6  per  cent,  protein 
2  1/2  or  3  per  cent.  Such  a  milk  is  often  seen  in  women  who  work 
hard  and  are  underfed.  A  third  tx-pe  of  abnormal  milk  is  very  low 
in  fat  and  sugar,  and  very  high  in  protein.  Its  composition  approxi- 
mates fat  I  to  I  I  '2  per  cent,  sugar  3  per  cent,  protein  3  1/2  to  4  per 
cent.  Such  a  milk  is  seen  in  "  highly  civiHzed  "  women  with  over- 
developed nervous  systems. 

SYMPTOMS  AND  DIAGNOSIS.— Disturbed  breast  feeding  is 
recognized  by  certain  symptoms.  The  babies  may  have  vomiting 
or  cohc,  or  abnormal  movements,  or  hunger-crying  and  restlessness, 
or  constipation.  Failure  to  gain,  or  loss  of  weight  may  be  the  chief 
symptom,  but  may  be  absent. 

For  purposes  of  practical  diagnosis  and  treatment,  cases  of  dis- 
turbed breast  feeding  may  be  divided  into  two  classes,  i.  Cases  in 
which  the  trouble  is  due  to  an  insufficient  breast  milk,  and  2.  cases 
in  which  the  trouble  is  due  to  a  bad  breast  milk.  In  the  first  class 
the  milk  is  insufficient  to  meet  the  nutritive  requirements  of  the  baby, 
but  does  not  cause  symptoms  of  indigestion.  In  the  second  class  the 
term  bad  means  that  the  milk  is  so  unsuited  to  the  digestive  powers 
of  the  baby  as  to  cause  symptoms  of  indigestion. 

Symptoms  of  Insufficient  Breast  Milk. — These  are  failure  to 
gain,  or  loss,  in  weight;  hunger-crying,  with  periods  of  excessive  somno- 
lence; constipation,  with  small  stools  of  increased  consistency,  but 
otherwise  well  digested  and  of  normal  color.  This  set  of  symptoms 
always  means  insufficient  milk.  The  milk  may  be  deficient  either 
in  quantity  or  in  quality,  and  for  purposes  of  treatment  it  is  important 
to  determine  which  condition  is  present.  When  the  baby  seems  satis- 
fied after  nursing,  but  wakes  up  and  cries  long  before  the  next  feeding 
time,  the  milk  is  apt  to  be  normal  in  quantity,  but  of  very  weak  com- 
position.    When  the  baby  is  not  satisfied  at  a  feeding,  wants  to  nurse 


Disturbances  of  Breast  Feeding  259 

a  long  time,  finally  going  to  sleep  on  the  breast,  the  deficiency  is 
probably  in  the  quantity.  The  diagnosis  however,  cannot  be  made 
with  any  certainty  on  this  evidence.  Insufficient  quantity  may  be 
recognized  by  the  method  of  weighing  the  baby  before  and  after 
nursing.  No  conclusion  can  be  based  on  the  amount  of  milk  taken 
at  a  single  nursing,  but  the  baby  must  be  weighed  before  and  after 
each  nursing  for  a  period  of  twenty-four  hours,  and  conclusions  are 
based  on  the  twenty-four  hour  quantity  of  milk  taken  by  the  baby. 
If  no  deficiency  in  quantity  is  found,  we  may  assume  that  the  de- 
ficiency is  in  the  quality.  This  diagnosis  can  be  confirmed  by  a 
chemical  analysis  of  the  milk,  which  usually  shows  a  marked  deficiency 
in  one  or  more  of  the  food  elements. 

Symptoms  of  Unsuitable  Breast  Milk. — The  babies  show  signs 
of  indigestion,  such  as  colic,  vomiting,  or  abnormal  stools.  In  mild 
cases  they  may  continue  to  gain  weight,  even  when  these  symptoms 
are  present;  in  moderate  cases  the  weight  is  stationary;  in  severe 
cases  there  is  loss  of  weight.  The  existence  of  symptoms  of  indiges- 
tion is  sufficient  evidence  for  the  diagnosis  of  unsuitable  breast  milk. 
The  result  of  analysis  may  give  us  some  idea  as  to  which  element  of 
the  milk  is  excessive,  in  proportion  to  the  infant's  digestive  power, 
but  conclusions  drawn  from  such  an  analysis  must  not  be  accepted 
as  too  positive,  as  the  peculiarity  of  the  child's  digestive  power  may 
be  so  great,  that  the  element  shown  by  analysis  to  be  most  excessive 
may  not  be  the  cause  of  the  symptoms. 

MANAGEMENT    OF    DISTURBED    BREAST    FEEDING.— 

These  disturbances  of  breast  feeding  are  never  an  indication  for 
weaning.  Every  effort  should  be  made  to  correct  them  before  arti- 
ficial feeding  is  even  thought  of. 

The  first  step  in  the  management  of  a  case  of  disturbed  breast 
feeding,  is  the  removal  of  any  possible  cause  in  the  hygiene  of  the 
mother.  The  most  common  cause  is  irregularity  of  nursing,  and  this 
is  the  cause  easiest  to  remove.  Absolute  regularity  must  be  insisted 
on,  and  any  other  bad  nursing  habit  must  be  corrected.  Every  detail 
of  the  mother's  daily  hygiene  must  be  scrutinized  and  all  abnormal 
conditions,  such  as  worry,  excitement,  improper  diet,  over-eating, 
constipation,  insufficient  exercise,  must  be  removed.  Some  cause 
may  be  found  which  is  not  sufficient  to  indicate  weaning,  but  which 
cannot  be  removed,  such  as  menstruation. 

After  the  hygiene  of  the  mother  has  been  placed  on  the  best  possible 
basis,  a  special  effort  should  be  made  to  affect  favorably  the  char- 
acter of  the  milk  by  other  means.  Such  an  effort  will  not  always 
be  successful,  and  the  regulation  of  breast  milk  by  means  of  diet  and 
exercise  cannot  be  carried  to  so  great  an  extent  as  was  formerly  sup- 
posed.    The  following  rules  may  be  used  as  a  guide,  in  such  eft"orts: 


260  Feeding 

1.  To  increase  the  total  quantity,  try  to  better  the  mother's  physical 
condition  by  careful  attention  to  all  hygienic  conditions.  Increase 
the  liquids  in  the  mother's  diet,  moderately,  not  to  excess.  En- 
courage the  mother  to  believe  that  she  will  be  able  to  nurse  her  infant. 
Gruel  is  a  good  addition  to  the  diet,  but  malt  liquors  do  no  good,  and 
rich  cocoa  or  chocolate  should  be  avoided.  It  is  probable  that  the 
special  galactogogues  mentioned  in  medical  literature  from  time  to 
time,  such  as  injections  of  pituitary  extract,  or  corpus  luteum,  or 
placenta,  do  no  good. 

2.  To  diminish  the  total  quantity,  restrict  the  fluid  a  little,  diminish 
the  food  taken  a  little,  and  keep  the  bowels  well  open. 

3.  To  increase  the  total  solids,  shorten  the  intervals  between  the 
nursing,  and  try  to  improve  the  mother's  general  condition  in  every 
possible  way. 

4.  To  diminish  the  total  solids,  lengthen  the  nursing  intervals,  and 
increase  the  food. 

Additional  rules  are  given  in  many  text  books  for  increasing  or 
diminishing  the  particular  food  elements,  fat,  carbohydrate,  and  pro- 
tein. Increasing  the  protein  in  the  food  was  formerly  supposed  to 
increase  the  fat  in  the  milk,  but  it  is  now  believed  that  there  is  no 
relation  between  the  protein  in  the  mother's  diet,  and  the  fat  in  the 
breast  secretion.  If  a  woman  is  underfed,  increased  fat  in  the  food 
will  cause  increased  fat  in  the  milk.  If  she  is  not  underfed,  the  fat 
in  her  milk  cannot  be  altered  by  any  special  dietary  regulations. 
Too  much  protein  in  the  milk  may  undoubtedly  be  caused  by  insuf- 
ficient exercise,  and  also  by  fatigue,  worry,  and  nervousness.  In  the 
treatment,  nothing  further  can  influence  the  protein  than  by  gen- 
erally correcting  all  unfavorable  hygienic  conditions.  There  is  no 
way  of  affecting  the  carbohydrate. 

When  the  disturbance  of  breast  feeding  is  due  to  unsuitable  milk, 
and  the  symptoms  are  those  of  indigestion,  every  effort  should  be 
made  to  aid  the  baby  by  relieving  the  symptoms  with  palliative 
measures,  while  waiting  for  the  treatment  of  the  mother  to  take  eft'ect. 
One  of  the  simplest  and  most  effective  of  these  measures,  is  to  try  to 
dilute  the  breast  milk  at  each  nursing.  This  is  done  by  giving  the 
baby  some  diluent  immediately  before  the  feeding.  Boiled  water 
may  be  used,  or  still  better,  some  slightly,  alkaline  solution,  for  in 
the  majority  of  instances,  the  symptoms  of  indigestion  are  due  to 
excessive  protein,  and  the  alkalies  have  a  favorable  influence  in  dis- 
turbances due  to  protein.  From  two  to  four  teaspoonfuls  each  of 
boiled  water  and  lime  water  may  be  given  immediately  before  each 
nursing,  or  a  weak  solution  of  sodium  bicarbonate,  i  grain  to  the  tea- 
spoon, may  be  used  instead  of  the  water  and  lime  water.  If  constipa- 
tion is  present,  boiled  water  with  about  10  drops  of  milk  of  magnesia 
may  be  used.  • 


Disturbances  of  Breast  Feeding  261 

After  all  these  measures  have  been  instituted,  continuance  of  the 
symptoms  of  indigestion  may  show  that  the  breast  milk  is  still  un- 
suited  to  the  baby's  digestion,  and  that  it  cannot  be  made  suitable 
either  through  regulation  of  the  mother,  or  through  palliative  meas- 
ures in  the  baby.  In  such  a  case,  further  treatment  depends  on 
whether  or  not  the  baby  is  gaining  in  weight,  for  many  babies  will 
gain  weight  on  breast  milk  in  spite  of  showing  symptoms  of  indiges- 
tion. If  the  baby  is  gaining  in  weight,  nothing  further  should  be 
attempted,  as  the  case  is  not  severe  enough  to  call  for  artificial  feeding. 
Palliative  measures  should  be  continued,  and  often,  as  the  baby  grows 
older,  its  digestive  power  improves,  or  the  composition  of  the  milk 
improyes,  and  the  symptoms  disappear.  If  the  baby  is  not  gaining, 
or  is  losing  in  weight,  some  artificial  food  must  be  given  in  addition 
to  the  breast  milk.  The  baby  must,  however,  not  be  weaned,  and 
breast  milk  should  still  be  the  basis  of  its  diet.  The  condition  of 
indigestion  is  usually  one  calling  for  diminution  of  the  total  breast 
milk  solids,  and  this  is  favored  by  lengthening  the  nursing  intervals. 
The  baby  may  now  be  fed  at  regular  intervals,  the  breast  and  the 
bottle  being  used  at  alternate  feedings.  This  tends  to  improve  the 
breast  milk,  by  lengthening  the  nursing  intervals,  without  disturbing 
the  child  by  lengthening  the  feeding  intervals.  Under  such  circum- 
stances the  breast  milk  frequently  improves  to  such  an  extent  that 
the  bottle  feedings  may  later  be  omitted.  If  the  symptoms  continue, 
but  the  baby  gains  weight,  nothing  further  need  be  done.  If  in  addi- 
tion to  the  persistence  of  indigestion,  there  is  no  gain  in  weight,  the 
physician  should  observe  carefully  whether  the  symptoms  are  most 
marked  after  the  breast,  or  after  the  bottle  feedings.  If  the  bottle 
feedings  give  no  lessening  of  the  symptoms,  the  composition  of  the 
artificial  food  must  be  changed  until  improvement  is  obtained.  If 
the  symptoms  are  relieved  by  the  bottle  feedings,  then  for  the  first 
time,  the  physician  should  begin  to  consider  passing  over  from  ma- 
ternal to  artificial  feeding.  Such  a  change,  however,  must  be  made 
gradually,  and  the  physician  must  assure  himself  that  the  artificial 
food  is  well  digested,  and  sufficient  to  nourish  the  infant.  Even 
when  this  is  clear,  the  breast  feedings  should  be  dropped  out  one  by 
one  only,  until  the  baby  is  gaining  weight,  and  as  many  breast  feed- 
ings as  possible  should  be  retained,  in  spite  of  their  causing  some 
indigestion.  The  activity  of  the  breast  should  in  the  meantime  be 
maintained  by  pumping,  so  that  the  breast  milk  will  remain  for  the 
physician  to  fall  back  upon,  if  necessary.  Only  when  it  becomes 
clear  that  the  breast  milk  is  so  bad  that  any  given  to  the  baby  causes 
disturbance,  and  prevents  gain  in  weight,  should  the  breast  be  dis- 
carded. When  mixed  feeding  is  thus  used  in  these  cases  of  unsuit- 
able breast  milk,  the  selection  of  the  first  artificial  food,  and  any 


262  Feeding 

subsequent  changes  made  in  its  composition,  are  to  be  guided  by  the 
principles  described  under  Artificial  Feeding. 

When  the  disturbance  of  breast  feeding  is  due  to  insufficiency  of 
the  breast  milk,  and  when  the  regulation  of  conditions  affecting  the 
mother,  and  special  efforts  to  increase  her  milk,  have  failed  to  relieve 
the  condition,  mixed  feeding  must  be  resorted  to.  The  artificial 
food  to  be  used  in  such  a  case  should  be  that  which  would  be  given  to 
a  normal  artificially  fed  baby  of  the  same  age,  as  described  under 
Artificial  Feeding.  In  insufficiency  of  breast  milk,  the  bottle  feed- 
ings should  not  be  given  to  alternate  with  the  breast  feedings,  but  to 
supplement  them.  Short  nursing  intervals  tend  to  increase  the  quan- 
tity and  total  solids  of  the  breast  milk,  and  the  intervals  must  not  be 
lengthened  by  alternating  the  breast  and  the  bottle.  If  the  deficiency 
is  in  the  quantity,  its  amount  may  be  judged  by  weighing  the  baby 
before  and  after  nursing,  and  the  amount  of  supplementary  food  to 
be  given  by  the  bottle  at  each  nursing  is  to  be  regulated  by  the  aver- 
age amount  of  the  deficiency.  If  the  deficiency  is  in  the  quality  of 
the  milk,  the  baby  must  be  allowed  to  take  only  a  part  of  his  feeding 
from  the  breast,  and  the  amount  which  he  ought  to  have  should  be 
made  up  from  the  bottle.  The  remaining  milk  in  the  breast  may  be 
removed  by  the  breast  pump,  but  the  breast  should  not  be  completely 
emptied.  However,  the  breast  pump  will  never  completely  empty  the 
breast.  Only  as  much  supplementary  artificial  food  should  be  given  as 
will  enable  the  baby  to  gain  weight.  Deficiency  in  quality  will  often 
correct  itself  under  this  treatment,  and  bottle  feedings  may  be  omitted. 

Deficiency  in  quantity  may  correct  itself,  but  usually  will  not.  As 
much  breast  milk  as  the  baby  can  get  should  always  be  given,  and 
breast  feeding  should  be  continued  as  long  as  there  is  any  milk  at  all 
in  the  breasts. 

WET-NURSING 

A  certain  number  of  mothers  are  unable  to  nurse  their  infants,  in 
spite  of  every  effort  on  the  part  of  the  mother,  and  care  on  the  part 
of  the  physician.  In  addition  to  the  positive  contraindications  to 
maternal  nursing  enumerated  above,  many  cases  are  seen,  in  which 
there  is  no  milk,  or  in  which  the  breast  secretion  soon  becomes  in- 
sufficient, and  then  disappears,  or  in  which  the  breast  milk,  in  spite 
of  every  effort,  remains  persistently  unsuited  to  the  child's  digestive 
power.  It  is  generally  supposed  that  the  mother's  milk,  as  a  rule, 
is  more  likely  to  be  suited  to  her  infant's  digestion  than  the  milk  of 
another  woman;  but  we  have  as  yet  too  few  cases  where  direct  investi- 
gation by  means  of  chemical  analysis  of  the  two  kinds  of  milk  has  been 
made,  to  lay  down  actually  as  a  fact  what  we  can  merely  grant  as  a 
supposition,  that  an  idiosyncrasy  in  the  mother's  milk  will  find  an 
analogue  in  her  infant's  digestive  powers.  The  reverse  of  this  proposi- 
tion has  also  been  held  to  be  true,  that  at  times  some  peculiarity  in 


Wet-Nursing  263 

the  mother's  milk  will  make  it  radically  unfit  for  her  infant.  The 
probability  is  that  analyses  will  show  either  that  these  varieties  of 
milk  are  poor  ones,  or  that  the  infants  have  unusually  weak  diges- 
tive powers. 

The  fact  that  every  mother  cannot  provide  as  good  a  milk  for  her 
infant  as  can  be  supplied  by  another  woman  finds  its  analogy  in  the 
inability  of  some  Jersey  cows  to  rear  their  own  calves 

When  it  has  been  demonstrated  that  it  is  impossible  or  inadvisable 
for  the  mother  to  nurse  her  infant,  some  other  food  must  be  sought. 
If  the  best  possible  food  for  the  human  infant  is  the  milk  secreted 
by  the  human  breast,  then  the  best  possible  substitute  for  the  mother's 
milk  is  the  milk  of  another  woman,  and  no  imitation  of  human  milk 
made  by  modifying  the  milk  of  an  animal  will  approach  the  special 
characteristics  of  human  milk. 

Upon  theoretical  grounds  therefore,  and  if  we  are  obliged  to  take 
into  consideration  nothing  more  than  the  requirement  of  supplying 
the  best  food  for  the  infant,  wet-nursing  would  be  indicated  in  ever}'- 
case  in  which  maternal  feeding  cannot  be  used.  There  are,  however, 
certain  practical  difficulties  in  wet-nursing.  In  the  first  place,  in 
most  communities,  satisfactory  wet-nurses  are  difficult  to  obtain, 
and  the  supply  would  by  no  means  meet  the  demand,  if  every  baby 
whose  mother  cannot  nurse  him  were  nourished  by  a  wet-nurse. 
There  are  obvious  inconveniences  about  the  introduction  of  a  wet- 
nurse  into  a  family,  which,  while  they  would  quickly  be  disregarded 
if  the  baby's  welfare  positively  depended  on  a  supply  of  human  milk, 
are  very  real  in  many  cases.  Artificial  feeding,  while  a  less  favorable 
means  of  nourishing  babies,  is  free  from  such  inconveniences,  and  is 
successful  in  a  large  proportion  of  cases.  It  is  therefore  becoming 
the  custom  to  use  artificial  feeding  in  the  majority  of  cases,  and  to 
save  the  few  wet-nurses  available  in  any  community  for  the  cases 
in  which  artificial  feeding  is  attended  by  special  difficulty. 

In  the  selection  of  a  wet-nurse,  the  physician  should  see  that  the 
woman  is  healthy,  and  free  from  any  suspicion  of  tuberculosis  or 
syphilis.*  She  should  be  preferably  under  thirty  years  of  age,  and 
should  be  of  pleasant  personality.  Her  lungs  should  be  examined, 
and  her  skin,  glands,  teeth,  throat,  scalp,  and  eyes  should  be  care- 
fully inspected.  The  nipples  should  be  long  enough  to  oft'er  no  obstacle 
to  sucking.  The  shape  and  size  of  the  breasts  is  no  indication  as  to 
the  amount  of  her  milk.  It  is  of  no  use  to  analyze  her  milk,  as  the 
normal  standard  of  breast  milk  is  not  definite  enough  to  permit  the 
drawing  of  conclusions  from  its  composition,  as  to  whether  it  will 
meet  the  baby's  requirements.  The  only  way  by  which  we  can  judge 
the  probable  quality  of  the  milk  is  by  the  appearance  of  the  wet-nurse's 
baby.  The  quantity  can  be  determined  by  a  series  of  weighings  of 
the  baby  before  and  after  nursing. 

*  The  Wasserman  reaction  should  be  tested  in  candidates  for  the  position  of  wet-nurse. 


264  Feeding 

It  is  by  no  means  as  essential  as  was  formerly  supposed,  that  the 
age  of  the  wet-nurse's  baby  be  about  the  same  as  that  of  the  baby 
she  is  to  nurse.  After  the  first  month,  the  changes  in  the  composition 
of  breast  milk,  are  not  very  important.  In  an  infant  from  one  to 
six  months  old,  the  milk  of  a  wet-nurse  whose  milk  is  one  to  six  months 
old  will  usually  sufhce. 

In  Boston  there  has  been  established  a  Wet-Nurse  Directory,  con- 
nected with  the  Infants'  Hospital,  of  which  the  object  is,  on  the  one 
hand,  to  help  poor  mothers  who  are  obliged  to  support  their  babies; 
through  the  Directory  they  can  earn  money,  without  being  separated 
from  their  young  infants.  On  the  other  hand,  the  Directory  pro- 
vides wet-nurses  for  physicians  who  need  breast  milk  for  their  cases. 
The  women  are  examined,  and  cared  for  medically  by  the  staff  of  the 
Infants'  Hospital,  and  those  out  of  employment  are  used  by  the  hos- 
pital. Thus  a  physician  applying  to  the  Directory,  is  suppUed  with 
a  wet-nurse,  in  whom  he  can  be  sure  of  a  plentiful  supply  of  good 
milk,  and  that  syphilis  and  all  other  diseases  are  excluded.  The 
price  paid  is  fixed  by  the  Directory. 

WEANING 

By  weaning  is  meant  the  discontinuance  of  breast  feeding,  and  the 
substitution  of  some  other  form  of  nourishment.  Weaning  should  be 
allowed  for  no  other  reason  than  for  the  mother's  or  baby's  best  good. 
It  should  never  be  permitted  for  the  mother's  convenience,  nor  for 
insufficient  grounds,  such  as  colic,  cracked  nipples,  menstruation,  or 
mild  symptoms  of  indigestion. 

Weaning  is  to  be  allowed  under  the  following  conditions: 

1.  In  the  normal  course  of  things,  when  the  baby  has  reached  the 
age  of  between  lo  and  12  months. 

2.  When  the  supply  of  breast  milk  completely  gives  out. 

3.  When  the  breast  feeding  is  attended  by  symptoms  of  indigestion, 
which  are  sufficiently  serious  to  cause  continual  failure  to  gain  in 
weight,  and  when  every  effort  to  relieve  this  condition  has  failed. 

4.  If  the  mother  becomes  pregnant. 

5.  If  the  mother  has  a  severe  acute  or  chronic  disease. 

There  is  a  tendency  to  wean  babies  upon  insufficient  grounds,  espe- 
cially to  give  up  breast  feeding  before  the  breast  milk  has  completely 
disappeared,  or  when  breast  milk  causes  comparatively  mild  symptoms 
of  indigestion.  Babies  should  not  be  weaned  except  under  the  con- 
ditions enumerated. 

Whenever  possible,  weaning  should  be  carried  out  gradually. 
Sudden  weaning  is  apt  to  produce  an  acute  disturbance  of  digestion. 
Gradual  weaning  may  be  used  in  all  the  conditions  in  which  weaning 
is  indicated,  except  pregnancy  or  severe  illness.  The  method  in 
which  weaning  is  carried  out  when  the  supply  of  breast  milk  fails, 


Weaning  265 

or  when  it  is  proved  finally  unsuited  to  the  baby,  has  been  described 
under  the  management  of  disturbed  breast  feeding.  In  many  cases 
the  breast  milk  begins  to  give  out  at  the  sixth  month,  and  supple- 
mentary bottle  feedings  have  to  be  used,  and  from  this  time  on,  wean- 
ing may  have  to  be  completed  at  any  time. 

In  babies  in  whom  there  is  no  diminution  in  breast  milk,  weaning 
should  be  carried  out  between  the  tenth  and  twelfth  months.  With 
no  apparent  diminution  in  the  breast  milk  in  a  child  nine  months  old 
or  over,  a  period  of  several  weeks  of  stationary  weight  should  be 
the  signal  for  beginning  weaning.  It  is  not  a  good  plan  to  continue 
breast  feeding  into  the  second  year,  just  because  the  baby  is  doing 
well.  The  late  months  of  lactation  require  close  watching,  as  there 
is  an  increasing  liability  to  sudden  disturbance.  The  prejudice 
against  weaning  in  hot  weather  is  exaggerated,  and  babies  may  be 
safely  weaned  in  summer,  if  they  are  given  a  pure,  properly  modified 
milk.  Nevertheless  a  baby's  digestive  power  is  depressed  by  heat, 
and  if  a  baby  has  just  reached  the  age  of  ten  months  at  the  beginning 
of  hot  weather,  I  usually  wait  until  cooler  weather  begins. 

The  gradual  weaning  is  carried  out  by  means  of  mixed  feeding. 
First  one  bottle  feeding  is  substituted  for  one  breast  feeding,  and  then 
the  number  of  bottle  feedings  is  gradually  increased,  while  the  breast 
feedings  are  gradually  diminished,  until  the  baby  passes  over  wholly 
to  the  bottle.  The  choice  of  food  to  be  given  in  the  bottle  is  to  be 
guided  by  the  principles  discussed  under  Artificial  Feeding.  Many 
well  babies  of  ten  to  twelve  months  can  be  given  whole  milk  at  once. 
Usually  at  this  age,  it  is  best  to  begin  with  a  dilution  of  whole  milk 
with  barley  water,  and  if  the  baby  has  shown  any  signs  of  indigestion, 
the  milk  dilution  must  be  weak.  The  strength  of  the  mixture  can 
be  gradually  increased  until  whole  milk  is  reached. 

In  babies  who  are  weaned  suddenly  because  of  pregnancy  or  illness 
in  the  mother,  or  at  an  earlier  age  because  of  symptoms  of  indigestion 
or  failure  of  breast  milk,  the  artificial  food  must  be  more  dilute. 
Whey  mixtures  are  usually  best  for  very  young  babies. 

It  is  sometimes  difficult  to  get  a  baby  accustomed  to  the  breast, 
to  take  the  bottle,  especially  when  it  has  reached  the  age  of  ten  to 
twelve  months.  Feeding  sometimes  requires  much  patience  and 
time  on  the  part  of  both  physician  and  nurse.  It  is  best  to  have 
some  one  other  than  the  mother  give  the  bottle,  if  possible.  It  is 
inadvisable  to  waste  time  trying  to  teach  infants  from  ten  to  twelve 
months  old  to  take  the  bottle;  it  is  better  to  teach  them  to  drink 
from  a  cup,  beginning  with  a  spoon  if  necessary.  Forcing,  or  too 
much  coaxing  are  objectionable.  If  the  food  is  offered  at  regular 
intervals,  and  taken  away  at  once  if  refused,  the  babies  often  begin 
to  take  it  after  a  time.  The  mother  must  be  assured  that  the  child 
will  not  starve,  even  if  a  period  of  thirty-six  or  even  forty-eight  hours 
elapses.     In  extreme  cases,  a  few  tube  feedings  may  be  necessary. 


III.     ARTIFICIAL  FEEDING 

PRELIMINARY  CONSIDERATIONS 

The  resort  to  artificial  feeding  is  usually  a  matter  of  necessity.  It 
is  the  exception,  not  the  rule,  for  an  American  mother  to  be  able  to 
feed  her  infant  exclusively  on  breast-milk  for  the  full  twelve  months. 
Supplementary  feeding  generally  begins  between  the  sixth  and  ninth 
months  and  often  earlier.  The  fact  that  a  mother  does  not  nurse 
her  infant  is  due  not  so  much  to  her  unwillingness  from  selfish  reasons, 
but  to  the  fact  that  she  is  a  victim  of  the  artificial  conditions  of  mod- 
ern life,  and  cannot  nurse  because  of  a  deficiency  either  in  the  quan- 
tity or  quality  of  her  milk.  The  great  majority  of  babies  fed  on 
substitutes  for  breast-milk  represent  cases  of  failure  of  breast  feeding. 
Whereas,  in  exceptional  cases,  one  may  solve  the  problem  by  securing 
a  competent  and  reliable  wet-nurse,  there  is  not  in  this  country  a 
sufficient  number  of  the  class  from  which  wet-nurses  are  derived  to 
meet  the  demand  made  by  the  'enormous  number  of  infants  whose 
mothers,  for  one  reason  or  another,  cannot  supply  their  natural  food. 
It  is,  therefore,  not  a  question  as  to  the  relativ^e  advantages  of  breast 
and  artificial  feeding,  which  must  be  considered,  but  one- of  how  best 
to  solve  the  problem  of  feeding,  by  artificial  methods,  the  constantly 
increasing  number  of  infants  who  must  be  reared  on  the  bottle.  There 
is  little  question  that  here  in  America  the  methods  of  artificial  feeding 
have  been  more  fully  developed  along  scientific  lines  than  in  any  other 
country,  but  the  principles  of  the  modification  of  cow's  milk  and  per- 
centage feeding  have  by  no  means  been  generally  adopted  by  the  pro- 
fession as  a  whole.  The  scientific  modification  of  milk,  and  percent- 
age feeding,  are  followed  for  the  most  part  by  those  whose  practice 
is  especially  in  the  line  of  children.  It  is  owing  to  the  unfamiliarity 
of  the  general  practitioner  with  these  principles  and  their  aversion 
to  mastering  the  details  of  a  somewhat  difficult  subject,  that  infant 
mortality  in  the  first  year  has  reached  such  alarming  proportions. 
The  introduction  of  the  proprietary  foods  has  not,  and  never  will, 
solve  the  problem  of  substitute  feeding  of  infants.  Fresh,  clean, 
cow's  milk  must  be  the  basis  of  successful  feeding,  and  the  knowl- 
edge of  the  principles  by  which  such  milk  may  be  modified  in  its  com- 
position and  adapted  to  the  varying  needs  of  human  infants,  becomes 
of  vital  importance  to  the  welfare  of  the  race. 


Cow's  Milk  267 

SOURCE  OF  FOOD 

REQUIREMENTS. — Human  milk,  the  food  which  nature  pro- 
vides for  infants,  contains  certain  food  elements,  which  we  must 
assume  to  be  necessary.  These  food  elements  are  fats,  carbohydrates, 
proteins,  and  certain  mineral  salts.  The  digestion  of  the  infant 
being  fitted  to  utilize  these  food  elements,  any  artificial  food  must 
contain  the  same  food  elements.  The  fat,  sugar,  protein,  and  salts 
should  correspond  as  closely  as  possible  chemically  to  the  same 
elements  as  found  in  human  milk,  and  should  correspond  also  in  their 
relative  proportions.  The  food  which  contains  these  elements  in  a 
form  most  closely  resembling  those  of  human  milk  in  their  chemistry 
and  proportions  is  the  mammary  secretion  of  another  animal.  The 
only  animal  milk  which  can  be  obtained  in  sufficient  quantity  for  use 
as  a  food  for  infants  is  the  milk  of  the  cow. 

Further  requirements,  are  that  the  food  must  be  fresh,  clean,  free 
from  injurious  bacteria,  that  the  number  of  bacteria  be  not  excessive, 
that  it  be  free  from  preservatives,  and  that  it  be  not  skimmed  nor 
diluted. 

COW'S  MILK.  The  Cow. — The  breeds  of  cows  which  are  con- 
sidered most  desirable  for  the  general  purposes  of  milk  production 
are  not  the  best  for  use  in  infant  feeding.  The  most  prized  breeds 
are  those  which  give  the  richest  milk,  such  as  the  Jersey  and  Guern- 
sey cows.  These  breeds  yield  a  milk  which  contains  a  greater  quan- 
tity of  fat  than  the  commoner  breeds,  such  as  the  Holstein.  More- 
over the  fat  globules  in  these  rich  milks  are  larger  than  are  the  globules 
in  the  milks  from  the  commoner  breeds.  One  feature  in  which  cow's 
milk  differs  most  markedly  from  human  milk  is  the  chemical  composi- 
tion of  the  fats.  Cow's  milk  contains  a  greater  proportion  of  the 
volatile  fatty  acids  than  does  human  milk,  and  this  difference  is  greater 
in  Jersey  milk  than  in  the  milk  of  the  commoner  breeds.  Many 
infants  who  cannot  digest  Jersey  milk  in  any  modification,  can  take 
the  milk  of  the  commoner  kinds  of  cows. 

There  is  a  theory  prevalent  in  some  communities,  that  the  milk 
of  one  cow  is  preferable  for  the  nutrition  of  an  infant  than  the  milk 
of  a  mixed  herd.  This  is  a  false  theory,  and  indeed,  quite  the  con- 
trary is  true.  The  milk  of  a  mixed  herd  of  cows  is  much  more  stable 
in  its  composition,  showing  much  less  variation  from  day  to  day, 
than  the  milk  of  a  single  cow.  Also,  any  single  cow  is  liable  to  some 
sudden  upset  which  changes  the  composition  of  her  milk.  An  upset 
in  one  cow  does  not  manifest  itself  to  any  great  extent  in  the  mixed 
milk  of  the  whole  herd. 

Composition  of  Cow's  Milk  Compared  with  Human  Milk. — 
Cow's  milk,  like  human  milk,  contains  fat  in  the  form  of  an  emulsion, 
and  carbohydrate,  protein,  and  mineral  salts  in  solution.     The  milk 


268  ■  Feeding 

varies  in  its  composition  just  as  does  human  milk.  The  variations 
depend  upon  the  breed  of  the  cow,  the  methods  of  feeding,  the  health 
of  the  animal,  the  season  of  the  year,  the  stage  of  lactation,  the  length 
of  the  interval  between  milkings,  the  portion  of  the  milk  withdrawn, 
and  many  other  conditions. 

The  analysis  of  an  average  good  cow's  milk  is  shown  in  the  table, 
compared  with  the  average  human  milk. 

Table  23 

Average  Cow's  Milk  Compared  with  Hitman  Milk 

cow's  MILK  HUMAN  MILK 

Specific  gravity 1.028  to  1.032  1-030  to  1.032 

Reaction Amphoteric  or  slightly  acid        Amphoteric 

Fat 4.00  per  cent  4.00  per  cent 

Lactose 4.75  per  cent  7.00  per  cent 

Protein 3.50  per  cent  1.50  per  cent 

Salts 0.70  per  cent  0.20  per  cent 

Water 87.05  per  cent  87.30  per  cent 

Fat  is  contained  in  cow's  milk  in  about  the  same  average  amount 
as  in  human  milk.  There  is,  however,  a  marked  difference  in  the 
chemistry  of  the  fat.  In  both,  the  greater  part  of  the  fat  is  in  the 
form  of  neutral  fat,  although  oleic  acid  is  in  greater  quantity  in  human 
milk.  The  chief  difference  is  that  cow's  milk  contains  a  greater  pro- 
portion of  the  lower  or  volatile  fatty  acids  than  does  human  milk. 
This  difference  is  very  important,  because  it  cannot  be  corrected  by 
any  known  method  of  cow's  milk  modification.  The  fat  globules, 
also,  are  slightly  larger  in  cow's  milk. 

The  carbohydrate  in  both  milks  is  lactose.  The  only  difference  is 
quantitative,  cow's  milk  containing  considerably  less  than  human 
milk. 

The  protein  of  cow's  milk  shows  both  quantitative  and  quahtative 
differences,  as  compared  with  human  milk.  The  quantity  of  protein 
is  much  greater  in  cow's  milk,  averaging  3.50  per  cent.  The  propor- 
tion of  casein  to  the  soluble  whey  proteids  (chiefly  lactalbumin)  is 
very  much  greater.  The  separation  of  the  different  forms  of  protein 
is  so  difficult  that  chemists  are  by  no  means  agreed  as  to  the  relative 
proportions  of  lactalbumin  and  casein  in  either  human  milk  or  cow's 
milk.  In  general,  the  whey  protein  and  casein  in  human  milk  are 
about  equal,  or  possibly,  the  soluble  protein  is  in  excess.  On  the 
other  hand,  it  is  generally  agreed  that  in  cow's  milk  the  casein  is  in 
excess.  Some  writers  place  the  proportion  of  casein  to  whey  protein 
in  cow's  milk  at  4  to  i,  others  at  3  to  i.  The  casein  of  cow's  milk  is 
much  more  coagulable  than  is  that  of  human  milk.  Whereas  the 
human  casein  is  only  slightly  coagulated  with  acids,  and  not  regularly 
by  rennet  plus  acid,  the  cow's  casein  is  readily  coagulated  both  with 
acids,  and  with  rennet  plus  acid.     The  curd  formed  in  gastric  digestion 


Cow's  Milk  269 

is  tough,  and  firm,  and  is  much  less  readily  dissolved  by  the  gastric 
juice. 

The  inorganic  salts  of  cow's  milk  also  show  differences  as  compared 
with  human  milk.  Their  total  quantity  is  more  than  three  times 
greater  than  in  human  milk.  There  are  great  differences  in  the 
amounts  of  the  various  salts  in  the  two  milks.  The  accompanying 
table  was  compiled  by  averaging  the  observations  of  a  number  of 
writers  on  this  subject. 

Table  24 

Composition  of  the  Ash  in  Human  and  Cow's  Milk,  in  per  cent 
(grams  per  loo  grams) 


Potassium  oxide.  . 

Sodium  oxide 

Calcium  oxide . . .  . 
Magnesium  oxide . 

Ferric  oxide 

Phosphoric  acid . . 
Chlorine 


cow  s 

WOMAN  S 

.1720 

•0750 

.0431 
.2117 
.0284 

.0217 
.0346 
.0063 

.0010 

.  0005 

■  2513 
•  0949 

.0471 
.1428 

While  all  the  salts  are  in  larger  percentage  in  cow's  milk  than  in 
human  milk,  the  relative  proportions  of  the  different  salts  differ 
greatly.  In  general  cow's  milk  contains  relatively  a  very  large  amount 
of  calcium  phosphate,  while  the  proportion  of  potassium  salts  and  iron 
in  cow's  milk  as  compared  with  human  milk  is  relatively  small.  There 
is  a  great  difference  in  the  form  in  which  phosphorus  is  present  in 
human  and  in  cow's  milk.  In  human  milk  three-quarters  of  the 
phosphorus  is  in  organic  combination,  while  in  cow's  milk  only  one- 
quarter  is  in  organic  combination.  The  iron  in  neither  human  milk 
nor  in  cow's  milk  is  sufficient  to  meet  the  demands  in  the  first  year 
of  life;  the  infant  must  depend  on  the  iron  stored  during  fetal  Hfe. 

Bacteriology  of  Cow's  Milk. — It  is  impossible  to  obtain  cow's 
milk  free  from  bacteria,  nor  even  as  relatively  free  from  bacteria  as 
is  human  milk.  Our  efforts  must  be  directed  toward  obtaining  milk 
which  is  wholly  free  from  pathogenic  bacteria  and  which  is  as  free  as 
possible  from  the  other  forms  of  bacteria  not  usually  harmful. 

Of  the  pathogenic  bacteria  transmitted  in  milk,  the  most  important 
is  the  tubercle  bacillus.  This  organism  has  been  frequently  found  in 
milk  supplies,  and  comes  from  cows  diseased  with  tuberculosis. 
Opinions  may  differ  as  to  the  exact  amount  of  the  danger  of  acquiring 
tuberculosis  through  milk,  but  there  is  no  doubt  that  contaminated 
milk  is  a  possible  source  of  tuberculosis.  I  believe  that  the  sale  of 
milk  from  cows  showing  on  physical  examination  evidences  of  tuber- 
culosis should  be  forbidden  by  law.  Whether  or  not  the  sale  of  milk 
from  cows  reacting  to  the  tuberculin  test  should  be  forbidden  is  still 
an  open  question.  I  should  advise,  for  use  in  infant  feeding,  only 
milk  from  tuberculin  tested  cows  having  negative  reactions. 


270  Feeding 

Streptococci  and  other  pyogenic  organisms  may  be  found  in  the 
milk  of  cows  having  disease  of  the  udder.  These  organisms  have 
been  shown  to  be  the  cause  in  some  cases  of  gastro-enteric  disease. 
The  milk  supply  should  be  obtained  from  a  source  in  which  milk 
from  cows  diseased  in  this  way  is  not  used. 

Certain  recognized  infectious  diseases  have  been  traced  to  milk 
infection.  The  diseases  known  to  have  been  transmitted  in  this 
way  are,  in  the  order  of  frequency,  typhoid  fever,  scarlet  fever, 
diphtheria,  dysentery,  and  cholera.  The  reason  that  dysentery 
occupies  so  low  a  place  in  this  list,  is  that  the  order  is  based  on  the 
frequency  with  which  the  infection  has  been  actually  traced  through 
the  milk.  Contaminated  milk  is  probably  the  usual  source  of  infec- 
tion with  the  bacillus  of  dysentery,  but  the  connection  with  a  definite 
case  of  dysentery  is  less  direct,  and  more  difficult  to  trace. 

The  other  bacteria  found  in  milk  come  from  a  variety  of  sources, 
entering  the  milk  chiefly  during  the  operation  of  milking.  They  may 
come  from  the  hands  and  clothing  of  the  milker,  from  the  dirt  faUing 
from  the  cow,  from  the  dust  of  the  stable,  and  from  many  similar 
sources.  A  great  variety  of  organisms  are  found  in  milk.  They  are 
for  the  most  part  harmless,  and  it  is  possible  that  some  of  them 
exercise  a  protective  action  by  keeping  out  more  harmful  forms.  Most 
of  them  belong  to  the  lactic-acid-forming  group,  and  are  concerned  in 
the  souring  of  milk.  In  too  great  numbers,  it  is  probable  that  these 
organisms  may  produce  changes  in  the  milk  which  may  cause  harm 
to  the  infant. 

Certified  Milk. — In  any  locality,  the  physician  should  use  in 
infant  feeding,  the  best  milk  supply  which  can  be  obtained.  Through 
the  concerted  efforts  of  physicians  and  others  interested  in  the  ques- 
tions of  pubHc  health  and  infant  mortahty,  attempts  have  been  made 
in  many  parts  of  North  America  to  improve  the  milk  supply.  The 
means  used  have  been  various;  in  some  places  more  or  less  stringent 
laws  have  been  passed  regulating  the  conditions  of  milk  production 
and  distribution;  in  other  places  milk  commissions  have  voluntarily 
undertaken  to  inspect  milk  supphes,  and  certify  milks  which  fulfil 
their  requirements,  the  community  being  informed  of  the  advantages 
of  milk  so  certified.  In  the  inspection  of  milk,  one  of  the  chief  criteria 
by  which  milk  supphes  are  judged,  is  the  count  of  the  number  of 
bacteria  contained  in  the  milk.  The  bacterial  count  is  valuable,  not 
so  much  because  a  high  bacterial  count  is  necessarily  a  sign  that  the 
milk  will  harm  the  baby,  as  because  it  is  a  guide  to  the  general  cleanH- 
ness  of  the  conditions  under  which  the  milk  is  produced. 

Every  physician  interested  in  the  subject  of  infant  feeding,  should 
be  familiar  with  the  present  status  of  pure  milk  production.  The 
details  of  this  subject  are  too  voluminous  to  be  incorporated  in  a 


Sterilization  and  Pasteurization  271 

text  book  of  this  kind,  and  the  reader  is  referred  to  the  reports  of  the 
various  milk  commissions. 

In  practice,  a  physician  should  recommend  the  use  of  certified  milk 
whenever  possible.  When  certified  milk  cannot  be  obtained,  he 
should  be  familiar  with  the  available  milk  supplies  in  his  locality, 
and  with  the  conditions  under  which  each  milk  is  produced,  and 
should  recommend  the  best. 

STERILIZATION    AND    PASTEURIZATION    OF    MILK.— 

Cow's  milk  may  be  heated  in  preparation  for  its  use  as  a  food  for 
infants.  The  object  of  heating  is  to  lessen  the  danger  of  damage 
to  the  infant  from  the  bacteria  contained  in  the  milk.  The  term 
"sterilization"  is  generally  used  to  designate  the  heating  of  milk 
to  a  boiling  temperature,  while  the  term  "pasteurization"  is  used 
to  designate  the  process  of  heating  at  a  temperature  lower  than 
boiling.  Neither  term  is  satisfactory.  Milk  is  not  rendered  bac- 
teriologically  sterile  by  the  process  of  boiling  ordinarily  employed, 
and  pasteurization  is  a  very  vague  term,  unless  it  is  definitely  stated 
at  what  temperature  and  for  how  long  the  milk  is  heated. 

The  Effect  of  Heat  on  the  Bacteriology  of  Milk. — The 
heating  of  milk  at  a  temperature  of  140°  F.  (60°  C.)  for  twenty 
minutes  will  destroy  the  recognized  pathogenic  non-spore-bearing 
organisms,  such  as  the  bacilli  of  typhoid,  diphtheria,  and  dysentery, 
and  the  vibrio  of  cholera.  Heating  at  a  higher  temperature  will 
destroy  these  organisms  in  a  shorter  time.  Many  of  the  organisms 
of  putrefaction  are  spore-bearing,  and  their  spores  are  highly  resis- 
tant to  heat;  some  of  them  have  been  shown  to  resist  boiling  for 
one  hour. 

Many  of  the  lactic-acid-forming  organisms  are  destroyed  by  heat, 
and  it  has  been  very  generally  believed  that  their  destruction  favors 
the  development  in  heated  milk  of  proteolytic  spore-bearing  organ- 
isms, which  may  form  highly  toxic  products.  Ayers  and  Johnson, 
however,  have  recently  shown  that  many  acid-forming  organisms 
are  not  destroyed  below  168°  F.  (75.6°  C.)  and  that  in  milk  pasteur- 
ized at  a  temperature  lower  than  this,  the  normal  process  of  souring 
takes  place,  though  somewhat  delayed.  No  chfference  was  found  in 
the  relative  numbers  of  the  acid-forming,  and  proteol^'tic  groups  in, 
pasteurized  milk,  from  that  seen  in  clean  raw  milk,  nor  in  the  rate 
of  multiplication.  There  is  at  present  no  definite  evidence  to  prove 
that  the  heating  of  milk  favors  the  growth  of  any  harmful  organisms. 

The  general  belief  is  that  the  heating  of  milk  has  no  effect  on 
any  bacterial  toxins  which  may  already  have  been  produced.  This 
is  only  partly  true.  True  soluble  bacterial  toxins  are  thermolabile, 
many  of  them  being  destroyed  at  a  temperature  of  140°  F.  (60°  C). 
The  endotoxins  are  for  the  most  part  resistant  to  heat. 


272  Feeding 

The  general  effect  of  heating  milk  at  140°  F.  (60°  C.)  or  orer, 
may  be  summarized  as  follows:  The  most  common  pathogenic  spore- 
bearing  organisms,  including  those  of  specific  infections,  are  de- 
stroyed, and  the  total  number  of  bacteria  is  lessened.  In  other 
words,  heating  brings  milk  bacteriologically  into  the  same  condition 
as  raw  milk  produced  under  the  most  careful  and  cleanly  conditions. 
The  subsequent  development  of  toxin-forming  spore-bearing  organ- 
isms is  possible,  if  the  milk  is  not  kept  at  a  temperature  suf5.ciently 
cold  to  inhibit  their  growth. 

The  Effect  of  Heat  on  the  CoiiPosiTioN  of  ]Milk. — The  boiling 
of  milk  produces  a  scum  upon  the  surface,  and  alters  the  taste  and 
smell  of  the  milk.  These  changes  are  not  marked  at  a  temperature 
lower  than  158^  F.  (70°  C).  Prolonged  boihng  changes  the  color 
to  brown  from  caramelization  of  the  sugar.  Heating  at  150"  F. 
(65°  C.)  for  over  thirty  minutes  delays  or  prevents  the  rising  of 
the  cream. 

When  milk  is  boiled,  some  of  the  mineral  salts  are  precipitated, 
and  the  inorganic  phosphorus  is  increased  at  ^  the  expense  of  the 
organic  compounds.  Certain  changes  are  produced  in  the  chemistry 
of  the  casein,  through  which  it  becomes  less  easy  of  coagulation 
by  rennet  plus  acid,  and  less  readily  acted  on  by  the  proteolytic 
digestive  ferments.  The  curd  formed  in  gastric  digestion  is  softer 
and  more  flocculent.     The  soluble  lactalbumin  is  entirely  precipitated. 

The  data  as  to  the  temperature  at  which  the  precipitation  of  the 
soluble  albumin  begins  are  not  in  agreement,  and  there  are  no  satis- 
factory data  as  to  the  temperature  at  w^hich  the  other  changes  begin. 
Hippius  concludes  that  heating  at  149°  F.  (65^^  C.)  for  thirty  min- 
utes produces  no  notable  changes  in  the  chemical  composition  of 
cow's  milk,  and  the  conclusion  is  probably  not  far  wrong. 

The  evidence  as  to  the  efi"ect  of  heat  on  the  ferments  of  cow's 
milk  is  very  inconclusive.  It  is  probable  that  some  of  them  are 
destroyed  by  heat,  while  it  has  been  shown  that  others  resist  various 
temperatures. 

The  Effect  of  Heat  on  the  Digestibility  and  Food  \^\lue 
of  Cow's  Milk. — The  more  or  less  general  behef  in  this  country 
has  been  that  babies  fed  continuously  on  cooked  milk  do  not  thrive 
as  wxll  as  babies  fed  on  raw  milk.  Recently  there  has  been  a  ten- 
dency to  examine  more  critically  the  evidence  on  which  ihis  assump- 
tion is  based,  with  the  result  that  more  or  less  doubt  has  been  thrown 
upon  its  truth.  The  evidence  has  been  derived  from  three  sorts  of 
experiments,  first,  in  artificial  digestion,  second,  on  animals,  and 
third,  on  babies.  Artificial  digestion  experiments  have  given  con- 
tradictory results,  some  writers  concluding  that  cooking  increases, 
and   others   that  it   diminishes,   the   digestibility   of  milk.     Animal 


Sterilization  and  Pasteurization  273 

experiments  are  mainly  in  agreement  that  young  animals  thrive 
better  on  the  raw  than  on  the  cooked  milk  of  their  own  species. 
The  experiments  on  babies  have  been  for  the  most  part  clinical  and 
statistical,  consisting  of  comparing  the  clinical  results  of  raw  and 
cooked  milk  in  the  feeding  of  large  series  of  babies.  The  results 
with  cooked  as  compared  with  raw  human  milk  resemble  the  results 
in  animals,  that  the  babies  do  better  on  the  raw  milk.  The  results 
with  raw  and  cooked  cow's  milk  are  open  to  the  objection  that  clinical 
and  statistical  evidence  of  this  kind  is  apt  to  be  misleading.  In 
general,  the  majority  of  investigators  have  failed  to  detect  any  differ- 
ence in  the  digestibility  and  food  value  of  cooked  and  raw  milk. 

As  to  the  particular  diseases  of  nutrition,  there  is  no  conclusive 
evidence  that  rachitis  is  more  frequent  in  babies  fed  on  cooked 
milk.  Scorbutus,  on  the  other  hand,  has  been  more  generally  asso- 
ciated with  the  use  of  cooked  food.  The  evidence  in  favor  of  the 
connection  between  scurvy  and  the  heating  of  milk  is  much  stronger 
than  any  other  evidence  as  to  the  value  of  heated  milk.  The  evi- 
dence, however,  is  almost  wholly  of  a  clinical  and  statistical  rather 
than  an  experimental  nature,  and  evidence  of  this  kind  can  never 
be  conclusive.  In  general,  the  evidence  is  that  in  all  large  series 
of  cases  of  scorbutus,  a  considerable  proportion  of  the  patients  have 
been  fed  on  heated  milk,  more  often  on  milk  which  has  been  boiled 
or  scalded  than  simply  pasteurized.  On  the  other  hand  scurvy  de- 
velops at  times  in  babies  fed  on  raw  milk,  and  even  in  breast-fed 
babies.  This  evidence  will  be  considered  at  greater  length  when 
scorbutus  is  described.  That  the  heating  of  milk  may  be  a  more 
or  less  important  cause  of  scorbutus  is  possible  if  not  probable,  but 
is  not  proven. 

Sterilization  or  Pasteurization. — The  higher  the  temperature 
at  which  milk  is  heated,  the  greater  are.  the  changes  of  chemical 
composition  produced.  While  it  is  still  an  open  question  how  great 
an  effect  these  changes  have  on  the  well-being  of  the  infant,  it  is 
obviously  better  to  avoid  them  if  possible.  The  object  of  heating 
the  milk  is  to  produce  the  destruction  of  certain  pathogenic  organisms, 
and  a  diminution  in  the  total  number  of  bacteria.  It  has  been 
shown  that  this  result  can  be  attained  by  subjecting  the  milk  to  a 
much  lower  degree  of  heat  than  the  boiHng  temperature.  Therefore 
pasteurization  should  be  preferred  to  sterilization.  The  tempera- 
ture of  the  pasteurization  should  be  as  low  as  is  consistent  with  the 
object  to  be  attained.  Pasteurization  at  a  temperature  lower  than 
140°  F.  (60°  C.)  is  not  efficient.  At  this  temperature  there  is  no 
change  in  the  color,  taste,  or  odor  of  the  milk,  and  but  little  change 
in  chemical  composition;  most  ferments  and  the  bactericidal  action 
of  milk,  are  unaffected,  while  most  bacterial  toxins  and  all  the  patho- 
18 


274  Feeding 

genie  non-spore-bearing  organisms  are  destroyed.  Therefore,  when 
heating  is  indicated,  pasteurization  at  140°  F.  (60°  C.)  for  twenty  min- 
utes should  be  chosen. 

Indications  for  Pasteurization. — Whether  or  not  milk  should 
be  pasteurized  is  a  question  which  must  be  decided  in  each  individual 
case.  Three  factors  must  be  considered  in  arriving  at  a  decision:  i, 
the  source  of  the  milk  supply;  2,  the  season  of  the  year;  and  3,  the 
time  taken  in  delivering  the  milk.  With  every  source  of  milk  supply 
except  the  very  cleanest,  pasteurization  should  be  employed  as  a 
routine  measure.  With  such  a  clean  milk  supply  as,  for  instance, 
certified  milk,  pasteurization  should  be  employed  whenever  the  milk 
has  to  be  transported  for  any  considerable  distance,  or  when  con- 
siderable time  elapses  between  milking  and  dehvery.  In  summer 
it  is  always  safer  to  pasteurize,  whatever  the  milk  supply;  occasionally 
an  exception  can  be  made  when  a  milk  is  used  which  is  known  to  be 
produced  and  dehvered  under  the  most  perfect  conditions.  In  gen- 
eral, pasteurization  should  be  employed  as  a  routine  measure,  except 
wdth  the  cleanest  milk  supply,  delivered  under  the  most  favorable 
conditions. 

When  an  infant  does  not  seem  to  thrive  on  pasteurized  milk,  it 
must  not  be  at  once  assumed  that  the  heating  of  the  milk  is  the  cause. 
Only  when  other  measures  have  been  thoroughly  tried,  the  pasteuriza- 
tion may  be  omitted  for  a  time  as  an  experiment.  The  only  risk 
supported  by  any  real  evidence  in  the  use  of  pasteurized  milk  is  the 
possible  deselopment  of  scorbutus.  Scorbutus  is  a  much  less  serious 
danger,  than  is  bacterial  infection  or  intoxication,  and  if  it  develops, 
it  is  easily  cured. 

Technique  of  Pasteurization. — It  is  better  to  pasteurize  milk 
for  each  feeding  in  a  separate  bottle,  than  to  pasteurize  the  whole 
twenty-four  hours'  food  supply  in  one  large  receptacle.  It  is  difficult 
to  maintain  so  large  a  quantity  of  milk  at  the  desired  temperature  for 
such  a  length  of  time  as  twenty  or  thirty  minutes,  and  the  results 
bacteriologically  have  been  shown  to  be  not  as  good  as  when  the  milk 
is  pasteurized  in  smaller  quantities. 

Each  feeding  should  be  put  in  a  separate  clean  bottle  which  has  been 
boiled,  and  the  bottles  should  be  stoppered  with  non-absorbent 
cotton.  The  bottles  are  then  placed  in  a  dish,  which  is  filled  with 
cold  water  up  to  a  level  with  the  milk  in  the  bottles.  The  dish  is 
then  placed  on  the  stove  and  heated  until  the  thermometer  suspended 
in  the  water  reaches  145°  F.  (62.7°  C).  The  dish  with  the  contents 
is  then  removed  from  the  stove,  covered  with  a  blanket,  and  allowed 
to  stand  for  thirty  minutes.  At  the  end  of  this  time  the  bottles  are 
taken  out  and  quickly  cooled  in  running  tap  water,  after  which  they 
are  placed  on  ice,  or  in  a  cold  place,  until  used. 


The  Examination  of  Milk 


275 


The  pasteurizers  on  the  market,  designed  for  home  use,  are  ah 
good.  They  are  somewhat  more  convenient,  though  not  more 
efficient,  than  the  method  described. 

THE  EXAMINATION  OF  MILK.— It  is  often  important  or 
desirable  for  the  physician  to  determine  the  composition  of  milk.  In 
the  case  of  human  milk,  the  analysis  occasionally  throws  some  light  on 
the  cause  in  disturbed  breast  feeding.  In  the  case  of  cow's  milk,  it 
is  often  important  to  determine  how  closely  a  certain  milk  used  in 
modifying  approaches  in  composition  the  milk  taken  as  the  basis  for 
calculating  percentages.     A  thorough  and  accurate  analysis  of  milk 


Fig.  74 


Sterilizer  and  thermometer 


Stand  lur  tubes 


Sterilizer  covered  with  cozy 
after  removal  from  heat 


can  only  be  carried  out  by  an  expert  chemist.  When  an  expert  chem- 
ist is  not  available,  the  physician  himself  can  frequently  carry  out  an 
analysis  of  clinical  value.  The  method  of  analysis  is  the  same  for 
both  human  milk  and  cow's  milk. 

The  Specific  Gravity  is  obtained  by  means  of  any  ordinary  hydro- 
meter, graduated  from  i.oio  to  1.040. 

The  Fat. — The  estimation  of  the  fat  is  the  most  important  in 
clinical  milk  analysis.  The  fat  can  be  measured  with  practically 
absolute  accuracy  by  means  of  the  Babcock  Fat-Tester,  or  by  some 
similar  centrifugal  apparatus.  Most  institutions,  and  many  physi- 
cians treating  many  infants,  keep  this  instrument  at  hand.  Its 
operation  is  very  simple.  To  a  given  volume  of  milk  is  added  a  cer- 
tain amount  of  sulphuric  acid,  the  quantities  varying  with  the  exact 
model  of  the  machine  used.     Pipettes  for  measuring  the  milk  and 


276 


Feeding 


acid  are  sold  with  the  machine.  The  milk  and  acid  are  mixed  in  a 
test-bottle  with  a  long  graduated  neck.  The  bottles  are  then  whirled 
in  the  centrifugal  machine  at  a  high  speed  for  five  minutes.  Hot 
water  is  then  added  to  bring  the  mixture  up  to  the  neck  of  the  bottle, 
and  then  the  bottle  is  centrifuged  for  two  minutes.  Hot  water  is 
again  added  to  bring  the  separated  fat  up  into  the  graduated  neck  of 
the  bottle,  the  machine  is  again  whirled  for  a  short  time,  and  the 
length  of  the  column  of  separated  fat,  as  measured  on  the  graduated 
bottle-neck,  is  read,  the  reading  giving  the  per  cent  of  fat  in  the 
mixture. 

Fig.  75 


Babcock  fat-tester 

For  those  who  have  no  Babcock  machine  at  hand,  a  simpler  method 
of  estimation,  of  approximate  accuracy,  is  by  means  of  Holt's  cream 
guage.  This  instrument  is  simply  a  graduated  stoppered  tube,  which 
is  filled  with  fresh  milk  to  the  zero  mark,  and  is  then  allowed  to  stand, 
corked,  at  room  temperature  for  twenty-four  hours.  The  reading 
is  taken  from  the  cream  line,  and  three-fifths  of  this  reading  is  taken 
as  the  percentage  of  fat  in  the  milk. 

The  Protein. — No  chemical  method  of  estimating  the  protein  is 
very  satisfactory.  The  most  accurate  is  that  in  which  the  protein 
is  precipitated  in  the  Esbach  tube  by  a  solution' of  phosphotungstic 
and  hydrochloric  acids,  the  reading  being  taken  at  the  end  of  twenty- 
four  hours.  An  approximate  idea  as  to  whether  the  protein  is  high 
or  low  may  be  found  by  considering  the  known  specific  gravity  in 
connection  with  the  known  percentage  of  fat.  In  this  estimation  we 
assume  that  the  percentages  of  sugar  and  mineral  salts  in  milk  are 
constant;  while  not  constant,  these  percentages  are  more  constant 
than  those  of  the  other  elements.  The  way  in  which  this  approximate 
conclusion  as  to  protein  is  made  is  shown  in  the  table: 


Sources  of  Difficulty  in  Artificial  Feeding        277 

Table  25 
Approximate  Estimation  of  Protein  from  Known  Fat  and  Specific  Gravity 

SPECIFIC  GRAVITY  FAT  PROTEIN 

High High  =  High 

High Low  =  Normal 

Low High  ==  Normal 

Low Low  ^  Low 

The  Carbohydrate  and  Salts. — These  elements  of  milk  cannot 
be  estimated  by  any  simple  chemical  method.  If  examination  by 
an  expert  chemist  is  not  necessary  or  available,  they  may  be  con- 
sidered constant. 

The  Microscopic  Examination  of  Milk. — This  should  be  part 
of  the  routine  in  the  examination  of  a  specimen  of  milk.  Both  the 
cream  and  the  centrifugalized  sediment  should  be  examined.  In  the 
cream  one  should  look  for  colostrum  corpuscles.  In  the  sediment 
one  should  look  for  dirt,  pus,  and  blood.  A  few  leucocytes  are  normal, 
but  any  excess  of  dirt,  pus,  or  blood,  should  cause  us  to  reject  the  milk. 
If  pus  be  present,  the  sediment  should  be  stained  for  bacteria,  and 
streptococci  should  be  sought. 

THE  MODIFICATION  OF  COW'S  MILK 

We  must  now  consider  the  most  important  part  of  the  subject  of 
the  artificial  feeding  of  infants,  which  concerns  the  adaptation  of 
cow's  milk  to  the  nutritive  requirements  of  the  infant.  While  cow's 
milk  is  the  only  available  food  which  in  composition  at  all  approaches 
the  food  designed  by  nature,  it  is  very  far  from  being  an  ideal  baby 
food.  We  have  seen  how  greatly  its  chemical  composition  differs 
from  that  of  human  milk.  That  these  differences  are  a  very  frequent 
cause  of  disturbances  of  digestion  and  nutrition  is  a  fact  proved  by 
years  of  clinical  experience.  The  existence  of  such  disturbances  in 
babies  fed  upon  cow's  milk,  has  led  to  a  great  number  of  investiga- 
tions which  have  been  made  with  the  object  of  discovering  whether 
there  are  any  means  by  which  the  digestibility  and  nutritive  value 
of  cow's  milk  as  a  food  for  infants  may  be  increased. 

THE  SOURCES  OF  DIFFICULTY  IN  ARTIFICIAL  FEED- 
ING.— There  are  two  factors  responsible  for  the  difficulties  encoun- 
tered in  the  artificial  feeding  of  infants.  The  first  is  to  be  found  in 
the  chemical  composition  of  cow's  milk,  which  makes  it  a  less  suitable 
food  for  infants  than  is  human  milk.  This  may  be  called  the  chemical 
difliculty.  The  second  is  to  be  found  in  the  variation  in  the  digestive 
powers  and  nutritive  requirements  of  dift'erent  babies.  This  may  be 
called  the  individual  difficulty.  The  relative  importance  of  these 
two  factors  has  been  very  largely  misjudged,  not  only  by  the  public, 
but  even  by  the  physicians  engaged  in  the  very  study  of  the  feeding 
problem.     Only  in  this  country  has  the  individual  factor  in  infant 


278  Feeding 

feeding  been  appreciated,  and  then  only  by  comparatively  few  physi- 
cians. In  Europe  the  entire  attention  of  investigators  has  been 
centered  upon  the  chemical  factor,  and  the  individual  factor  has  been, 
and  still  is,  almost  entirely  neglected,  yet  it  is  the  individual  factor 
which  is  really  the  more  important  practical  source  of  difhculty  in 
artificial  feeding. 

One  great  obstacle  to  advance  in  our  knowledge  of  the  principles 
of  artificial  feeding,  has  been  the  generally  prevalent  idea,  existing 
not  only  in  the  minds  of  the  public  in  general,  but  even  in  the  minds 
of  physicians  and  of  specialists  in  infant  feeding,  that  there  is  some- 
tvhere,  yet  to  be  discovered,  a  bahy  food  of  transcendent  value  which 
will  solve  the  problem  of  infant  feeding,  and  which  can  be  fed  success- 
fully to  babies  in  general.  It  is  possible  that  in  the  minds  of  those 
who  have  studied  the  subject,  this  idea  takes  a  little  different  form. 
Such  men  will  look  upon  one  method  of  modifying  cow's  milk  as 
better  than  another  method.  To  regard  one  method  of  modifying 
cow's  milk  as  better  than  another,  must  mean  that  it  is  regarded  as 
better  for  babies  in  general,  and  that  it  is  the  best  method  which  has 
been  found.  This  opinion  carries  with  it  the  idea  that  there  is  a 
best  method  of  modifying  cow's  milk,  and  that  is  only  the  ideal  baby 
food  expressed  in  other  words. 

The  nature  of  the  feeding  problem  is  such  that  an  ideal  baby  food 
can  never  be  attained.  The  factor  of  individual  variation  plays  too 
great  a  part,  and  we  shall  never  be  able  to  feed  babies  as  a  class,  nor 
to  find  a  food  or  method  which  will  be  best  for  babies  in  general. 
The  modification  of  cow's  milk  which  is  best  for  one  bab}^  will  always 
be  worst  for  some  other. 

Great  advances  have  been  made  from  time  to  time  in  the  attempts 
to  solve  the  chemical  difficulty  of  infant  feeding.  The  most  careful 
and  painstaking  researches  on  the  physiology  and  pathology  of  diges- 
tion in  infancy,  on  infantile  metabolism,  and  on  the  effect  upon  diges- 
tion and  metabolism  of  various  methods  of  modifying  cow's  milk 
have  been  made.  These  investigations  have  given  us  additions  to 
the  sum  of  our  knowledge  of  these  subjects,  the  value  of  which  cannot 
be  overestimated.  Usually  the  results  of  each  research  of  this  kind 
has  suggested  some  new  practical  method  by  which  cow's  milk  can 
be  modified  to  greater  advantage.  There  has  been  an  unfortunate 
tendency  to  hail  each  new  method  of  modifying  milk  suggested  by 
researches  of  this  kind,  as  the  best,  if  not  the  ideal  method  of  feeding 
babies.  The  new  method  is  regarded  not  as  ranking  equally  in  value 
with  previous  methods,  but  as  being  a  step  in  advance  which  will 
supersede  older  methods  in  the  feeding  of  babies.  Thus  we  have 
passed  through  successive  stages  in  which  modification  with  whey, 
with  cereal  diluents,  with  various  alkalies,  with  maltose,  with  lactic 
acid  ferment,  with  precipitated  casein  has  each  in  turn  been  regarded 


Sources  of  Difficulty  in  Artificial  Feeding  279 

as  a  better  method  of  modifying  cow's  milk  than  its  predecessors. 
Even  if  the  particular  investigator  has  not  himself  regarded  his  addi- 
tion to  the  methods  of  milk  modification  as  a  new  method  of  feeding 
which  shall  supersede  others,  the  readers  of  his  reports  have  so  re- 
garded it.  The  way  in  which  the  results  in  practice  of  any  new  method 
of  modifying  milk  have  been  studied  and  reported  has  been  such  as 
to  perpetuate  the  idea  of  its  superior  value.  The  new  method  of 
feeding  is  applied  to  a  large  series  of  babies,  the  clinical  results  are 
studied,  and  a  statistical  report  is  published.  Such  reports  are  very 
misleading,  because,  studied  in  this  way,  every  new  method  of  modi- 
fying milk  gives  good  statistical  results.  The  individual  variation 
in  babies  is  so  great,  that  in  any  series  a  large  number  of  babies  will 
do  well,  and  a  considerable  number  of  babies  will  do  better  with  the 
new  method  of  feeding  than  with  any  other. 

This  tendency  to  overestimate  the  value  of  the  new  methods  of 
modifying  milk  suggested  from  time  to  time  by  research,  and  to  apply 
them  to  the  feeding  of  babies  in  general,  has  been  most  unfortunate. 
There  has  never  been  any  logical  ground  for  beheving  that  any  one 
of  them  is  better  for  babies  as  a  class  than  any  other.  Each  method  is 
based  on  some  actual  discovered  fact  in  infantile  digestion  and  meta- 
bohsm.  Each  older  method  has  been  in  its  day  just  as  well  supported 
by  clinical  and  statistical  evidence  as  is  the  new  method.  The  old  facts, 
if  brought  out  by  proper  research,  remain,  and  the  newly  discovered 
facts  are  only  additional,  but  do  not  contradict  the  older  ones.  There 
are  babies  who  do  better  on  one  method,  and  babies  who  do  better 
on  another.  We  should  not  discard  any  method  of  modifying  milk 
based  on  some  discovered  fact  about  the  infantile  digestion,  simply 
because  some  additional  fact  has  been  discovered  which  suggests  a 
different  method.  We  should  regard  every  method  of  modifying  milk 
based  upon  adequately  demonstrated  facts  concerning  the  digestion  and 
metabolism  of  the  infant,  as  having  its  own  particular  value,  as  being 
particularly  fitted  to  meet  the  digestive  peculiarities  of  individual  babies. 
We  should  regard  all  such  methods  as  constituting  our  stock  of  weapons, 
which  we  need  to  combat  the  many  difficulties  springing  from  the  peculiar 
chemistry  of  cow's  milk,  and  from  the  limitless  variation  in  the  baby's 
digestive  powers  and  requirements.  We  should  hail  each  new  research 
and  the  practical  application  to  feeding  suggested  by  it,  not  as  a  new  or 
better  method  of  feeding  babies,  but  as  a  new  addition  to  our  slock  of 
weapons,  a  new  resource,  which  will  have  its  particidar  use  in  a  problem, 
the  nature  of  which  is  such,  that  we  need  all  the  resources  at  present  avail- 
able, and  more. 

CALORIC  REQUIREMENTS  AND  DIGESTIVE  REQUIRE- 
MENTS.— One  of  the  most  important  efforts  to  devise  a  method  of 
feeding  babies  in  general,  based  upon  research,  is  that  which  is  some- 


280  Feeding 

times  called  the  caloric  method  of  feeding.  This  is  based  on  the 
so-called  minimum  caloric  requirement  of  a  normal  baby.  A  number 
of  infants  who  were  thriving  and  gaining  normally  in  weight  were 
investigated,  and  the  energy  value  of  the  food  taken  each  twenty-four 
hours  was  estimated  in  calories.  The  quantity  of  food  taken  varied 
with  the  weight  of  the  baby,  and  the  food  required  to  maintain  proper 
nutrition  was  measured  in  terms  of  calories  per  kilogram  of  body 
weight.  From  the  averages  of  large  series  of  babies,  was  deduced  the 
minimum  caloric  requirement,  which  represents  the  minimum  number 
of  calories  per  kilogram  of  body  weight  which  each  baby  must  receive 
daily  in  order  to  thrive. 

The  Minimum  Caloric  Requirements. — As  estimated  in  this  way 
the  minimum  caloric  requirement  is  as  follows: 

Table  26 

Mininuim  Caloric  Requirement 

Birth-  6  months 120  cal.  per  kilo 

6-12  months 100  cal.  per  kilo 

12-24  months 90  cal.  per  kilo 

Protein  Requirement. — Protein  is  that  element  of  the  food  which 
is  used  in  the  building  up  of  the  body  tissues,  while  it  is  the  fats 
and  carbohydrates  which  are  concerned  with  energy  production. 
From  metabolism  experiments  has  been  deduced  a  protein  require- 
ment for  the  normal  baby.  The  protein  requirement  thus  estab- 
lished is  open  to  the  same  objections  as  caloric  requirement,  as  it 
is  based  on  the  method  of  averaging  variations.  I  believe,  however, 
that  variations  are  not  so  extreme,  and  that  the  protein  require- 
ment is  often  a  useful  guide.  It  is  from  i.o  to  1.5  grammes  of  pro- 
tein daily  per  kilogram  of  body  weight.  Most  milk  modifications, 
unless  extremely  low  in  protein,  more  than  fulfil  this  requirement. 

Caloric  Requirement  as  a  Basis  for  Feeding. — This  study  of 
caloric  requirement  led  to  the  idea  that  here  at  least  was  a  definite 
and  satisfactory  basis  for  the  artificial  feeding  of  babies.  Under  this 
system  the  physician  reckons  the  minimum  daily  caloric  require- 
ment from  the  weight  of  the  baby,  and  then  chooses  the  food  with 
the  primary  object  of  at  least  meeting  this  requirement.  The  amount 
of  fat,  carbohydrate,  and  protein  is  designed  to  produce  the  requisite 
calories.  In  case  of  indigestion,  if  one  element  in  the  food  must  be 
reduced,  the  others  must  be  proportionately  increased,  in  order  to 
maintain  the  caloric  value  of  the  food. 

Caloric  requirement  as  a  basis  for  feeding, — a  caloric  method  of 
feeding — is  open  to  numerous  very  serious  objections.  In  the  first 
place,  the  figures  for  minimum  caloric  requirement  were  obtained 
by  the  method  of  averaging  a  given  number  of  observations,  which 


Caloric  Requirements  281 

method  gives  a  very  misleading  result  whenever  individual  variation 
plays  much  part.  The  caloric  requirement  even  of  normal  babies 
has  been  shown  to  be  very  variable.  This  variation  is  still  more 
extreme  in  sick  babies,  or  with  babies  in  poor  condition.  Moreover, 
caloric  requirement  varies  on  account  of  a  number  of  other  factors, 
such  as  the  surface  area,  and  the  activity  of  the  baby.  Finally,  and 
most  important  of  all,  the  nutrition  of  the  baby  depends  upon  the 
quantity  of  food  assimilated,  not  upon  the  quantity  ingested,  and  the 
net  caloric  value  of  the  food  cannot  be  estimated.  In  babies  with 
deficient  power  of  digestion,  less  food  is  absorbed  and  utilized,  and 
indigestion  does  more  harm  in  preventing  a  child  from  thriving  than 
anything  else.  Babies  cannot  be  fed  as  a  class  on  a  caloric  basis, 
because  the  variation  in  their  power  of  digesting  and  absorbing  food 
is  too  great.  Clinical  experience  has  shown  the  widest  extremes, 
some  babies  gaining  weight  on  a  caloric  intake  far  below  the  so- 
called  minimum,  and  others  failing  to  gain  on  a  caloric  intake  far 
in  excess. 

Digestive  Requirement. — In  choosing  an  artificial  food  for  a 
baby,  our  first  aim  must  always  be  to  give  the  baby  a  food  suited 
to  its  power  of  digestion.  Our  principal  difficulty  is  in  meeting 
variation  in  digestive  power.  We  are  also  confronted  by  a  varia- 
tion in  caloric  requirement.  Consequently  we  must  assume  that  every 
baby  has  digestive  and  caloric  requirements  such  that  some  partic- 
ular combination  of  the  food  elements  in  milk,  modified  in  some 
particular  way,  will  be  the  best  food  for  that  baby.  Our  problem 
is  to  find  that  combination,  or  at  least,  if  not  the  best  combination, 
one  that  will  be  suitable.  To  solve  this  problem,  we  must  consider 
first  all  the  chemical  difficulties  in  digesting  cow's  milk,  and  the 
methods  of  milk  modification  which  have  been  devised  to  solve  these 
difficulties. 

Of  course  the  great  majority  of  babies  have  not  such  defective 
powers  of  digestion  as  call  for  any  special  measures.  For  such  babies, 
certain  general  rules  for  the  modification  of  cow's  milk  in  the  prepa- 
ration of  their  food,  can  be  stated.  The  difficult  cases  call  for  all 
our  knowledge,  and  all  our  resources. 

Value  of  Caloric  Estimation. — To  estimate  the  caloric  value 
of  an  infant's  food,  and  to  compare  it  with  the  theoretical  minimum 
caloric  requirement,  is  a  procedure  which  is  often  useful  in  the  con- 
duct of  a  case  where  artificial  feeding  is  employed.  Sometimes,  for 
instance,  we  may  be  in  doubt  whether  failure  to  gain  in  weight  is 
due  to  defective  digestion  and  assimilation,  or  to  insuflicient  food 
ingestion.  In  such  a  case,  caloric  estimation  may  be  a  great  help. 
Always,  however,  the  calculation  of  calories  should  be  used  as  a 
check,  not  as  our  principal  guide. 


282  Feeding 

PERCENTAGE  FEEDING.— The  world  owes  to  Professor 
Thomas  Morgan  Rotch  a  great  debt,  for  elaborating  the  theory  of 
percentage  feeding,  which  is  now  very  generally  accepted  by  the 
leading  teachers  and  writers  in  America  as  the  basis  of  the  modern 
scientific  feeding  of  infants.  Percentage  feeding  is  often  wrongly 
spoken  of  as  if  it  were  some  special  method  of  feeding  infants,  which 
is  considered  by  its  users  as  superior  to  other  so-called  methods. 
Those  who  thus  misjudge  the  theory  appear  to  think  that  it  in- 
volves some  particular  formula  or  set  of  formulae  for  the  feeding 
of  infants,  some  special  combination  of  percentages  of  superior  value. 

Percentage  feeding  is  not  at  all  a  method  of  feeding  in  the  sense 
that  it  chooses  any  particular  method  of  modifying  the  composition 
of  the  infant's  food.  It  is  primarily  simply  a  method  of  recording 
the  characteristics  of  the  food  given  to  the  infant.  Instead  of  record- 
ing the  food  in  terms  of  mixtures  of  various  ingredients  such  as  cream, 
milk,  lactose,  barley  water,  and  so  forth,  the  food  is  recorded  in  terms 
of  the  percentage  of  the  various  elements:  fat,  protein,  lactose,  maltose, 
or  starch,  etc.  contained  in  these  mixtures.  Even  when  a  baby  is  fed 
on  a  simple  dilution  of  cow's  milk,  the  record  is  made  in  terms  of 
the  percentage  of  fat,  lactose,  and  protein  contained  therein. 

The  advantage  of  such  a  system  of  record  is  that  it  gives  a  common 
terminology  in  infant  feeding,  and  a  common  basis  by  which  various 
methods  of  modifying  milk  may  be  compared,  both  as  to  theory, 
and  as  to  practical  results.  A  physician  may  feed  a  baby,  for  ex- 
ample, on  a  mixture  of  milk  and  barley  water,  and  change  the  food 
from  time  to  time  by  gradually  increasing  the  milk  and  diminishing 
the  barley  water.  If  he  thinks  of  his  food  in  terms  of  the  relative 
ounces  of  milk  and  barley  water,  he  has  no  way  of  comparing  his 
method  of  modifying  milk  with  other  methods;  and,  if  he  publishes 
his  results,  they  will  have  no  value  to  other  physicians  until  they 
have  estimated  just  what  quantity  of  the  various  food  elements  the 
baby  was  getting  in  that  food.  To  advance  in  our  knowledge  of 
infant  feeding,  we  must  be  able  to  compare  our  results  one  with 
another,  and  must  also  be  able  to  compare  our  work  with  the  pub- 
lished work  of  others.  Such  a  comparison  necessitates  a  common 
basis,  a  universal  manner  of  record.  It  is  the  tolerance  or  intol- 
erance of  the  infant  for  the  various  food  elements,  which  is  the  final 
result  in  infant  feeding.  Therefore  we  must  know  the  amount  of 
each  food  element  given,  as  recorded  in  percentage  form. 

As  record  in  terms  of  percentages  became  customary,  physicians 
naturally  came  to  think  of  foods  as  combinations  of  percentages  of 
the  essential  elements,  rather  than  in  terms  of  mixtures  of  ingredi- 
ents. The  essential  thing  in  choosing  a  food  for  an  infant  is  to 
arrange  the  quantity  and  kind  of  fat,  sugar,  and  protein  in  such  a 
way  as  to  rtieet  the  digestive  and  nutritive  requirements  of   the 


Modification  of  Cow's  Milk  283 

infant.  As  our  knowledge  of  digestion  and  nutritive  requirements 
is  derived  from  percentage  records,  we  have  come  to  think  first  of 
the  percentages  we  wish  to  give,  and  which  we  record.  Then  we 
give  the  proper  directions  for  obtaining  and  preparing  the  food. 

THE  MODIFICATION  OF  COW'S  MILK— THEORY 

To  utiHze  all  the  resources  of  artificial  feeding,  the  physician  must 
be  familiar  with  every  method  of  modifying  cow's  milk  which  is 
"in  good  use."  Those  methods  are  in  good  use  which  are  based  on 
adequately  proven  facts,  or  on  plausible  theories,  regarding  the 
infantile  digestion  and  metabolism,  or  which  are  supported  by  ac- 
cepted clinical  evidence.  In  some  methods  a  combination  of  two 
or  more  principles  is  used.  The  methods  of  modifying  milk  depend- 
ing on  a  single  principle,  which  are  at  present  in  good  use,  are  ten 
in  number.     They  are  the  following: 

1.  The  dilution  of  milk  or  cream  with  the  addition  of  lactose. 

2.  The  addition  of  starch  to  cow's  milk  mixtures. 

3.  The  addition  of  alkalies  to  cow's  milk  mixtures.     Of  the  alka- 
lies there  are  three — 

a.  Lime  water. 

b.  Sodium  bicarbonate. 

c.  Sodium  citrate.* 

4.  The  peptonization  of  cow's  milk  mixtures. 

5.  The  addition  of  whey  to  cream  dilutions — the  so-called  "split 
protein." 

6.  The  addition  of  other  soluble  carbohydrates  than  lactose  to 
cow's  milk  mixtures. 

7.  The  addition  of  the  lactic  acid  ferment  to  cow's  milk  mixtures. 

8.  The  addition  to  the  food  of  precipitated  casein. 

9.  The  cooking  of  cow's  milk  mixtures. 

10.  The  use  of  "homogenized"  milk  mixtures. 

These  various  methods  may  be  combined  in  any  variety  of  ways. 
A  cow's  milk  dilution  may  be  peptonized,  or  have  lime  water  or 
barley  water  added.  Two  combinations  of  principles  have  been  so 
widely  known  as  methods  of  modifying  milk,  that  they  deserve 
special  mention.     They  are — 

1.  "Malt  soup"  modifications,  a  combination  of  maltose,  starch, 
and  cooking. 

2.  Albumin  milk,  a  combination  of  lactic  acid  milk  and  precipitated 
casein. 

In  order  to  use  to  best  advantage  these  various  methods  of  modify- 
ing milk,  it  is  necessary  to  know  the  scientific  basis  of  each  one.     In 

*  It  may  be  objected  that  sodium  citrate  is  not  really  an  alkali.  In  the  physiology 
of  digestion  it  acts  in  a  manner  so  like  the  lime  water  and  sodium  bicarbonate,  that  it 
is  most  conveniently  classified  with  them. 


284  Feeding 

other  words,  we  must  know  exactly  how  each  method  of  modifying 
affects  the  composition  of  cow's  milk,  what  effect  such  modification 
of  the  composition  has  on  the  infant's  digestion  and  assimilation, 
and  how  the  milk  is  fitted  to  meet  individual  variation.  The  fol- 
lowing is  a  summary  of  the  present  state  of  our  knowledge  of  milk 
modification. 

MILK  AND  CREAM  DILUTION  WITH  THE  ADDITION 
OF  LACTOSE. — This  is  the  method  of  modifying  cow's  milk  to 
which  the  term  percentage  modification  was  first  applied.  The  origin 
of  this  method  was  an  effort  to  produce  a  cow's  milk  mixture,  the 
composition  of  which  would  approach  as  closely  as  possible  to  that 
of  human  milk.  The  chief  difference  between  human  milk  and  cow's 
milk  is  that  the  latter  has  a  higher  proportion  of  protein  as  com- 
pared with  fat.  In  cream  the  protein  is  lower  in  proportion  to  the 
fat,  and  if  cream  be  diluted,  the  proportion  found  in  human  milk  may 
be  imitated.     For  example,   the   percentage  formula  of  an  average 

human  milk  is — ■ 

Fat  4.00      Lactose  7.00      Protein  1.50 

and  of  an  average  cow's  milk  is 

Fat  4 .  00      Lactose  4 .  50      Protein  3 .  50 

A  cream  can  be  obtained  which  has  an  approximate  formula  of — 

Fat  8 .  00      Lactose  4 .  00       Protein  3 .  00 

If  this  be  diluted  one-half  with  water,  the  resulting  mixture  has  a 
composition  of — 

Fat  4.00       Lactose  2.00       Protein  i .  50 

If  now  sufficient  dry  lactose  be  added  to  this  mixture  to  make  a  5% 
solution,  the  resulting  mixture  will  have  a  formula  of — 

Fat  4.00       Lactose  7.00       Protein  1.50 

which  is  that  of  an  average  human  milk. 

It  must  not  be  supposed  that  the  above  figures  are  absolutely 
accurate.  They  are  given  only  as  an  example  of  how  the  composi- 
tion of  cow's  milk  may  be  altered,  by  dilution  and  the  addition  of 
lactose,  to  imitate  human  milk.  The  actual  modification  would 
involve  certain  fractions,  which  have  been  omitted. 

The  modification  of  cow's  milk  to  imitate  an  average  human  milk 
by  no  means  solved  the  problem  of  infant  feeding.  Certain  essential 
chemical  differences  remained,  such  as  the  composition  of  the  fats 
and  mineral  salts,  and  the  relative  proportion  of  soluble  protein  and 
casein.  Moreover,  the  imitation  of  an  average  human  milk  did  not 
meet  the  important  factor  of  individual  variation  in  digestive  powers 


Modification  of  Cow's  Milk  285 

and  requirements.  In  this  method,  of  dilution  with  the  addition 
of  lactose,  we  are  by  no  means  confined  to  the  imitation  of  an 
average  human  milk.  By  diluting  creams  of  various  fat  percent- 
ages we  may  alter  at  will  the  proportion  of  fat  to  protein.  By 
diluting  skimmed  milk  we  may  alter  at  will  the  percentage  of  protein 
without  affecting  the  fat.  By  adding  varying  amounts  of  dry  lac- 
tose, we  may  alter  at  will  the  percentage  of  lactose.  Thus,  by  this 
method  of  diluting  in  various  proportions  milks  of  various  fat  per- 
centages, with  the  use  of  dry  milk  sugar,  we  may  alter  at  will  the 
percentage  of  fat,  lactose,  and  protein  in  our  food,  within  very 
wide  limits. 

There  are  certain  limits  to  the  variety  of  percentage  combinations 
which  we  can  obtain.  Any  percentage  of  fat  whatever  is  possible. 
The  minimum  protein  depends  upon  how  strong  a  cream  we  can 
obtain.  A  cream  of  higher  fat  percentage  can  be  obtained  by  cen- 
trifugal separation  than  by  gravity  separation,  and  the  former  would 
give  a  lower  minimum  protein.  The  maximum  protein  is  3.50,  the 
percentage  in  undiluted  milk.  The  maximum  lactose  percentage  has 
no  Umit,  but  the  minimum  varies  with  the  percentage  of  protein, 
as  all  milk  and  cream  contains  lactose.  The  following  table  shows 
the  practical  limits  of  milk  modification,  by  this  method,  with  home 
and  laboratory  modification,  assuming  that  16  per  cent  is  the  highest 
fat  obtainable  in  cream  by  the  gravity  method. 

Table  27 

Practical  Limits  of  Milk  Modification — Minimum  Protein,  with  Varying 
Fat  Percentages 

Minimum  Protein 
home  modification,  laboratory, 

fat  percentage  gravity  cream,  1 6%      centrifugal  cream,  32% 

.50  .10  .05 

1. 00  .20  .10  ■ 

I-50  .30  .15 

2.00  .40  .20  . 

2.50  .50  .25 

3 .  00  .60  .30 
350  .70  -35 

4 .  00  .80  .40 

Table  28 

Practical  Limits  of  Milk  Modification — Minimum  Lactose,  with  Varying 
Protein  Percentages  , 

PROTEIN  PERCENTAGE  MINIMUM  LACTOSE 

.50  .70 

I . 00  I . 40 

1.50  2.10 

2  .  CX3  2  .  80 

2-5°  3-5° 

3.00  4.20 

3-50  4-5° 


286  Feeding 

This  method  of  modifying  cow's  milk  makes  no  attempt  to  solve 
the  chemical  difhculties  involved  in  the  composition  of  the  cow's 
milk  fat  and  mineral  salts  and  in  the  high  proportion  of  casein, 
except  by  simple  dilution.  If  any  of  these  elements  is  the  cause 
of  trouble,  the  quantity  of  that  element  can  be  reduced,  and  if  neces- 
sary, other  elements  can  be  increased.  The  chief  value  of  this  method 
of  modifying  cow's  milk  lies  in  enabling  us  to  meet  the  factor  of  indi- 
vidual variation  in  digestive  power  and  requirements.  It  provides 
us  with  an  almost  unlimited  number  of  combinations  of  the  three 
main  elements  of  an  infant's  food.  The  variations  in  the  infant's 
digestive  powers  are  primarily  variations  in  its  ability  to  digest 
and  assimilate  fat,  sugar,  and  protein.  Consequently,  this  method 
of  modifying  milk,  by  which  the  relative  amounts  of  these  elements 
can  be  varied  at  will,  is  fundamental  in  infant  feeding,  and  is  the 
basis  of  all  efforts  to  solve  any  given  problem. 

MODIFICATION  WITH  STARCH.— The  value  of  using  some 
cooked  cereal  preparation  as  a  diluent  in  cow's  milk  modification 
has  long  been  recognized.  When  a  solution  of  starch,  such  as  is  found 
in  diluents  like  barley  water,  is  present  in  a  cow's  milk  modifica- 
tion, the  curd  formed  by  the  precipitation  of  the  casein  in  the  normal 
process  of  digestion,  is  more  finely  divided,  and  is  easier  of  digestion. 
The  action  of  the  starch  in  preventing  the  formation  of  large  casein 
curds  is  not  chemical,  but  mechanical,  due  to  the  colloidal  nature  of 
the  starch  solution. 

If  the  starch  possesses  this  colloidal  action,  there  must  be  some 
minimum  quantity  of  starch  necessary  to  produce  it.  This  quantity 
is  that  necessary  to  give  a  sufficient  concentration  of  the  starch  solu- 
tion, and  it  must  therefore  be  proportioned  to  the  total  quantity  of 
the  food  mixture.  The  minimum  quantity  necessary  to  obtain  in 
full  the  colloidal  action  of  the  starch,  is  .75  per  cent. 

It  must  be  remembered  that  starch  is  a  readily  fermentable  carbo- 
hydrate, and  that  if  it  is  not  spHt  by  the  amylolytic  action  of  the 
pancreatic  secretion,  it  will  ferment.  Babies  vary  in  their  power  of 
digesting  and  absorbing  starch.  It  is  not  known  at  just  what  age 
the  amylolytic  function  develops,  as  this  is  probably  very  variable. 
The  power  of  starch  digestion  may  be  present  at  birth,  or  may  develop 
at  some  subsequent  period.  It  is  usually  established  at  six  months. 
Starch  indigestion  and  fermentation  is  more  likely  to  occur  in  younger 
babies. 

MODIFICATION  WITH  ALKALIES.— The  original  basis  for 
the  use  of  alkalies  in  cow's  milk  modification  was  a  further  attempt 
to  imitate  the  composition  of  human  milk.  It  was  believed  at  that 
time  that,  cow's  milk  being  acid  and  human  milk  alkaline,  the  addi- 


Modification  of  Cow's  Milk  287 

tion  to  cow's  milk  mixtures  of  5  per  cent  lime  water  would  cause  them 
to  resemble  human  milk  in  alkalinity.  It  has  since  been  learned  that 
human  milk  is  not  alkaline  but  amphoteric,  and  that  the  addition  of 
lime  water  to  cow's  milk  does  not  cause  it  to  resemble  human  milk 
in  reaction.  In  the  meanwhile,  however,  clinical  evidence  had  been 
accumulating,  which  was  strongly  in  favor  of  the  value  of  lime  water 
in  certain  cases  of  difficult  digestion. 

A  theoretical  explanation  of  the  value  of  lime  water  was  sought  in 
the  fact  that  many  cases  of  disturbed  digestion  are  accompanied  by 
symptoms  suggesting  acidity,  such  as  "  sour  stomach,"  and  acid  stools. 
There  is  no  experimental  evidence  in  support  of  the  theory  that  the 
alkalies  act  by  neutralizing  the  products  of  acid  fermentation,  although 
such  action  is  quite  possible,  and  may  explain  some  cases  in  which 
benefit  is  clinically  quite  evident. 

The  only  positive  and  scientific  data  which  we  have,  on  which  to 
base  our  use  of  the  alkalies  in  infant  feeding,  is  to  be  found  in  the 
work  of  Hamburger  and  Slicka,  who  published  the  results  of  an  ex- 
tended study  on  the  action  of  the  alkalies  in  gastric  digestion.  The 
truth  of  their  conclusions  has  been  confirmed  by  subsequent  investi- 
gators. They  have  shown  that  the  alkalies  combine  chemically  with 
the  casein  of  cow's  milk,  and  that  as  a  result  of  such  chemical  union, 
the  precipitation  of  the  casein  by  the  rennin  and  acid  of  the  stomach, 
is  delayed,  and  the  character  of  the  curd  is  altered.  The  curd,  when 
thus  modified,  is  easier  of  digestion  by  the  gastric  juice.  Further- 
more, if  sufficient  alkali  be  present,  the  acid  of  the  gastric  juice  is  so 
neutralized,  that  the  precipitation  of  the  casein  is  entirely  prevented. 
On  this  basis,  our  indication  for  the  use  of  the  alkalies  is  when  we  wish 
to  delay  curd  formation  with  modification  of  the  curd,  or  to  prevent 
it  entirely. 

If  the  alkalies  have  this  action,  there  must  be  some  definite  quan- 
tity of  alkali  which  gives  the  action  at  its  best.  As  the  action  of  the 
alkali  is  a  chemical  one,  the  alkali  entering  into  actual  chemical  union 
with  the  casein,  this  optimum  quantity  of  alkali  must  be  in  direct 
proportion  to  the  quantity  of  casein,  with  which  the  alkali  combines. 
As  milk  and  cream  both  contain  casein,  and  are  assumed  for  practical 
purposes  to  contain  the  same  percentage  of  casein,  the  quantity  of 
casein  in  a  cow's  milk  modification  varies  directly  with  the  quantity 
of  milk  and  cream  in  the  mixture.  The  optimum  quantity  of  alkali, 
that  needed  to  produce  the  desired  result,  is,  therefore,  expressed  as 
a  percentage  of  the  quantity  of  milk  and  cream  used  in  the  prepara- 
tion of  the  food. 

The  quantities  of  alkali  which  produce  the  various  results  which 
we  must  have  in  view  when  using  the  alkalies  on  this  basis  have  been 
satisfactorily  determined  by  experiment,  and  are  shown  in  the  table. 


288  Feeding 

Table  29 
Quantity  of  Alkali  Expressed  in  Terms  of  Per  Cent  of  the  Milk  and  Cream 

TO  DELAY  CURD  FORMATION   TO  PREVENT  PRECIPITATION 
AND  MODIFY  THE  CURD        OF  THE  CASEIN  CURD 

Lime  water 20.00%  50.00% 

Sodium  bicarbonate . .  o .  68%  i .  70% 

Sodium  citrate 0.20%  0.40% 

As  far  as  the  different  alkalies,  lime  water,  sodium  bicarbonate, 
and  sodium  citrate  are  concerned,  all  three  have  the  same  general 
action.  They  dift'er  one  from  another  only  in  the  character  of  the 
casein  curd  formed  under  their  influence.  With  one  alkali  the  curd 
is  more  porous,  with  another  more  gelatinous,  and  so  forth.  CUn- 
ically,  certain  individual  cases  are  found  in  which  some  one  of  the 
alkalies  works  best,  but  there  is  no  guide  as  to  which  we  shall  choose. 
This  work  on  the  alkalies  is  the  only  definite  basis  for  their  use  estab- 
lished by  experimental  evidence.  In  the  majority  of  cases  our  use 
of  the  alkalies  should  be  upon  this  basis.  We  should  order  alkali  with 
a  definite  purpose,  to  produce  a  known  result,  in  the  quantity  which  best 
accomplishes  our  purpose,  and  which  is  expressed  in  per  cent  of  the  milk 
and  cream  in  the  mixture. 

There  is  another  basis  for  the  use  of  the  alkalies,  not  definitely 
established  by  experimental  evidence,  but  suggested  by  chnical 
results.  The  work  of  Hamburger  and  SHcka  is  confined  solely  to 
the  action  of  the  alkalies  in  gastric  digestion.  Clinical  evidence 
suggests  that  the  alkalies  may  have  some  influence  after  the  food 
leaves  the  stomach,  possibly  by  neutraHzing  the  acid  products  of 
excessive  carbohydrate  fermentation  in  the  intestine.  While  such 
influence  is  not  proven,  it  is  sufficiently  possible  to  warrant  the  use 
of  alkaH  on  this  basis.  In  such  a  case,  however,  the  physician  should 
have  a  definite  reason  for  using  alkaH.  The  amount  of  alkali  used 
on  this  basis  is  not  to  be  proportioned  to  the  milk  and  cream,  for  the 
theoretical  action  of  the  alkaH  involves  no  chemical  union  with  the 
casein.  We  do  not  know  the  amount  of  alkaH  necessary  to  neutraHze 
excessive  acid  fermentation.  All  we  can  do  is  to  order  alkaH  in  large 
excess.  In  the  case  of  lime  water,  such  an  excess  would  be  expressed 
as  about  25%  of  the  total  mixture. 

PEPTONIZATION.— Cow's  miUi  modifications  may  be  peptonized 
through  the  agency  of  a  pancreatic  extract  obtained  from  an  animal. 
The  object  is  to  effect  a  pre-digestion  of  the  protein,  which  is  con- 
verted into  peptone  by  the  active  ferment  trypsin.  The  amount  of 
peptone  formed  varies  with  the  duration  of  the  process.  If  milk  is 
peptonized  for  ten  minutes,  only  a  part  of  the  protein  is  converted 
into  peptone,  and  the  milk  is  not  altered  in  taste.  If  milk  is  pepton- 
ized for  twenty  minutes,  most  of  the  protein  is  converted,  and  the 
mixture  has  a  bitter  taste.     Peptonization  represents  one  method  of 


TOTAL 

WHEY 

iCTOSE 

PROTEIN 

PROTEIN 

CASEIN 

4-50 

3-50 

.70 

2.80 

7 

I -50 

■30 

1.20 

7 

I -SO 

•75 

•75 

Modification  of  Cow's  Milk  289 

overcoming  the  difficulty  presented  by  the  high  percentage  of  protein 
in  cow's  milk.  With  the  development  of  other  methods  of  dealing 
with  protein  indigestion,  the  use  of  peptonization  has  become  more 
and  more  hmited. 

WHEY  MIXTURES.  THE  SPLIT  PROTEIN.— This  method  of 
modifying  cow's  milk  is  based  on  a  further  attempt  to  imitate  Nature. 
When  cow's  milk  is  modified  by  the  method  of  milk  and  cream  dilu- 
tion, with  the  addition  of  lactose,  the  relatively  high  proportion  of 
casein  to  the  lactalbumin  and  other  soluble  proteins  persists.  In 
cow's  milk  about  four-fifths  of  the  protein  is  casein,  whereas  in  human 
milk,  only  about  half  is  casein.  Thus  if  the  formula  of  cow's  milk  be 
expressed  in  terms  of  the  two  forms  of  protein,  four-fifths  of  the  total 
protein  will  be  casein,  and  in  a  cow's  milk  mixture  made  by  milk  and 
cream  dilution  with  the  addition  of  lactose,  designed  to  imitate  human 
milk,  the  same  proportion  will  hold.  The  table  shows  such  a  formula 
compared  with  human  milk. 

Table  30 

FAT 

Cow's  milk 4 

Modified  cow's  milk 4 

Human  milk 4 

The  older  ideas  on  the  difficulties  of  digesting  cow's  milk  in  arti- 
ficial feeding  laid  especial  stress  on  the  high  casein  content  of 
cow's  milk  as  the  probable  cause.  The  three  methods  of  modifying 
cow's  milk  just  described,  namely,  modification  with  starch,  with 
alkahes,  and  with  peptonization,  were  all  designed  to  meet  this 
difficulty  presented  by  high  casein.  As  will  be  seen  from  the  table, 
in  any  formula  made  with  cow's  milk,  the  baby  is  required  to  digest 
much  more  casein  than  he  would  have  to  digest  with  the  same  total 
amount  of  human  milk  protein.  The  method  of  modifying  with 
whey  was  designed  to  overcome  this  disadvantage,  in  another  way, 
by  altering  the  relative  amounts  of  whey  protein  and  casein  in  such  a 
way  as  to  imitate  more  closely  the  relative  amounts  in  human  milk. 

If  a  cream  of  high  fat  percentage  be  diluted,  the  protein  is  much 
reduced.     If,  for  example,  all  cream  having  a  composition  of — 

Fat  16  Lactose  4  Protein  3,00 

be  diluted  one  to  four  with  water,  the  formula  of  the  mixture  will  be — 

Fat  4  Lactose  1. 00  Protein     .75 

If  this  formula  be  expressed  in  terms  of  soluble  whey  protein  and 
casein  it  will  be — 

Fat  4  Lactose  1. 00  Whey  protein     .15  Casein  .60 

19 


290  Feeding 

Now  suppose  whey  be  used  as  a  diluent  instead  of  water.  Whey 
contains  no  fat,  and  no  casein,  but  only  lactose  and  whey  protein. 
If  the  formula  of  whey  be  considered  as  approximately — 

Fat  o  Lactose  s  Whey  protein  i .  oo  Casein  o 

and  if  whey  be  used  as  the  diluent,  and  if  one-half  of  the  mixture 
be  whey,  we  have  added  to  our  mixture  with  the  w^hey  the  following- 
Fat  o  Lactose  2  .  50  Whey  protein    .  50  Casein  o 

If  we  add  together  the  percentages  obtained  by  diluting  our  cream 
one-quarter,  and  making  up  the  remaining  three-quarters  with  whey 
one  half,  water  one-quarter,  we  have  to  add  together — 


Fat  4 
Fato 

Lactose  i.oo 
Lactose  2 .  50 

WTiey  protein 
Whey  protein 

■15 
•50 

Casein  .60 
Casein  0 

and  this  gives- 

- 

Fat  4 

Lactose  3 .  50 

Whey  protein 

•65 

Casein  .60 

and  if  we  now  add  enough  lactose  to  raise  the  total  sugar  percentage 
to  7,  we  have — 

Fat  4  Lactose  7 .  00  Whey  protein     .  65  Casein  .  60 

which  is  not  far  from  the  formula  of  human  milk. 

The  figures  given  above  are  not  accurate,  but  are  given  as  an 
example  of  the  method  by  which  the  relative  proportions  of  whey 
protein  and  casein  may  be  altered  by  the  use  of  whey  as  a  diluent. 

In  this  method  of  modifying  cow's  milk,  we  are  not  confined  to 
the  imitation  of  an  average  human  milk.  By  using  various  propor- 
tions of  cream  or  milk  and  whey,  we  can  obtain  various  proportions 
of  fat,  whey  protein,  and  casein,  and  are  thus  provided  with  a  great 
number  of  percentage  combinations,  fitted  to  cope  with  the  factor 
of  individual  variation  in  digestive  powers  and  requirements. 

There  are  certain  limits  to  the  percentage  combinations  obtainable 
by  the  use  of  whey.  The  percentage  of  whey  protein  in  whey  is 
about  .90  per  cent,  and  a  whey  mixture  cannot  have  a  whey  protein 
percentage  much  higher  than  this.  The  low  limit  of  casein  is  deter- 
mined by  the  amount  of  fat  required.  In  general,  .90  per  cent  is 
considered  the  upper  limit  for  the  whey  protein,  and  .50  per  cent 
the  low  casein  Hmit  in  home  modification,  while  in  laboratory  feeding 
with  a  centrifugal  cream  used  as  a  basis,  the  casein  may  be  reduced 
as  low  as  .25  per  cent. 

It  must  be  remembered  that  the  primary  object  of  whey  modifi- 
cation is  to  reduce  the  casein  in  the  food  without  reducing  the  total 
protein.  We  can  use  a  food  of  high  nitrogen  content,  without  im- 
posing the  burden  on  digestion  which  the  high  casein  of  cow's  milk 


Modification  of  Cow's  Milk  291 

would  otherwise  involve.  It  must  further  be  remembered,  however, 
that  such  modification  would  only  be  useful  in  cases  in  which  the 
casein  is  the  cause  of  digestive  trouble.  Also,  the  minimum  lactose 
obtainable  with  whey  mixtures  is  much  higher  than  with  ordinary 
milk  and  cream  dilution,  because  the  whey  used  as  a  diluent  in 
place  of  boiled  water  has  a  high  lactose  content.  The  high  per- 
centage of  the  mineral  salts  of  cow's  milk,  which  is  ordinarily  reduced 
by  the  dilution  of  milk  and  cream,  is  not  reduced  in  whey  mixtures, 
as  whey  contains  a  high  mineral  content.  In  cases  where  lactose, 
or  the  high  salt  content  of  cow's  milk  might  be  the  cause  of  trouble, 
whey  mixtures  would  do  harm.  On  the  other  hand,  the  split  pro- 
tein method  is  the  best  theoretical  method  of  dealing  with  casein 
intolerance,  as  it  is  the  method  used  by  Nature  as  exemplified  in 
human  milk. 

MODIFICATION  BY  THE  ADDITION  OF  SOLUBLE  CAR- 
BOHYDRATES OTHER  THAN  LACTOSE.— The  majority  of 
cow's  milk  modifications  require  the  addition  of  a  certain  quantity 
of  lactose,  because  the  lactose  content  of  cow's  milk  is  low  in  com- 
parison with  human  milk,  and  is  often  still  further  lowered  by  dilu- 
tion. The  substitution  of  some  other  form  of  soluble  carbohydrate 
for  this  extra  lactose,  did  not  originally  spring  from  the  results  of 
any  scientific  investigation  of  the  infantile  digestion  and  metabolism, 
but  was  adopted  upon  purely  empirical  grounds.  Indeed,  this 
method  of  modifying  cow's  milk  owes  its  adoption  to  the  marked 
success  sometimes  seen  in  an  individual  case,  attending  the  use  of 
some  patent  baby  food.  It  sometimes  happened  that  a  baby  fed 
most  carefully  on  scientific  principles,  with  every  kind  of  milk  modi- 
fication suggested  by  our  knowledge  of  the  subject  of  artificial  feed- 
ing, would  fail  to  thrive;  finally  the  mother,  caught  by  the  lure  of 
some  advertisement,  or  by  the  suggestion  of  a  friend  or  neighbor, 
would  try  some  patent  baby  food,  with  the  most  startling  success. 
Such  cases,  of  course,  did  not  mean  that  the  patent  food  was  a  better 
food  for  babies  than  all  the  resources  of  scientific  feeding,  but  that 
it  embodied  some  principle  in  the  modification  of  cow's  milk  which 
was  suited  to  the  digestive  peculiarities  of  that  individual  baby.  It 
is  the  aim  of  scientific  artificial  feeding  to  contain  in  its  stock  of 
weapons  every  principle  which  may  bring  success  in  an  individual 
case.  It  theirefore  became  necessary  to  study  the  principles  involved 
in  the  various  patent  foods.  This  study  showed  that  most  of  the 
patent  foods  are  mainly  carbohydrate  preparations,  and  that  their 
essential  feature  is  that  they  contain  other  carbohydrates  than  lac- 
tose, such  as  maltose,  dextrine,  dextrose,  or  cane  sugar.  Therefore 
it  was  obvious  that  there  were  babies  whose  individual  peculiarities 
made  them  better  fitted  to  utilize  these  other  carbohydrates,  and 


292  Feeding 

the  substitution  of  these  sugars  for  lactose  had  to  become  one  of 
our  stock  of  resources  in  deahng  with  the  problem  of  artificial  feeding . 

More  recently,  light  has  been  thrown  on  the  probable  scientific 
explanation  of  the  value  of  a  change  in  carbohydrate.  The  various 
carbohydrates  usually  employed  in  milk  modification  are  disaccha- 
rids,  differing  in  the  character  of  the  component  monosaccharids 
into  which  they  are  split  in  the  course  of  digestion.  Lactose,  for 
example,  is  spht  into  dextrose  and  galactose,  saccharose  is  split 
into  dextrose  and  levulose,  while  maltose  is  split  into  dextrose  and 
dextrose.  These  monosaccharids  differ  in  the  readiness  with  which 
they  are  absorbed,  and  in  the  readiness  with  which  they  undergo 
bacterial  fermentation.  Dextrose  is  the  substance  most  easily  ab- 
sorbed, and  is,  moreover,  the  only  sugar  which  can  be  immediately 
utilized  for  energy  production,  without  undergoing  the  process  of 
glycogen-storing  in  the  liver.  Galactose  and  levulose,  on  the  other 
hand,  while  less  easily  utilizable  for  energy  production,  are  much 
more  readily  fermentable.  In  any  case,  therefore,  in  which  there 
was  difficulty  in  digesting  and  absorbing  sugar,  or  in  which  there 
was  difi&culty  in  obtaining  from  other  food  elements,  such  as  the 
fat,  a  sufficient  supply  of  fuel  for  energy  production,  maltose  would 
be  the  preferable  sugar.  This  explains  the  good  results  often  seen 
when  maltose  is  used  in  cases  of  severe  atrophy. 

On  the  other  hand.  Nature  does  not  provide  for  the  infant  the 
easily  utilized  maltose,  but  the  more  fermentable  lactose.  There 
must  be  a  reason  for  this.  Kendall  has  shown  that  the  normal  bac- 
terial processes  in  the  infant's  intestine  are  those  of  carbohydrate 
fermentation,  and  that  a  sufiicient  supply  of  fermentable  carbohy- 
drate must  remain  behind  in  the  intestine,  in  order  to  maintain  the 
normal  character  of  .the  intestinal  flora.  It  is  probably  for  this  pur- 
pose that  lactose  is  provided  by  Nature,  and  under  this  theory,  lactose 
would  be  preferable  to  maltose  in  babies  whose  powers  of  digestion 
and  assimilation  showed  no  very  wide  deviations  from  the  normal, 
or  in  babies  whose  digestive  disturbances  are  traceable  to  abnormal 
bacterial  processes. 

This  explanation,  while  not  conclusively  proven,  is  sufQciently 
satisfactory  to  serve  as  a  basis  for  our  choice  of  carbohydrate  in  feed- 
ing, and  there  is  no  other.  Our  choice  must  be  made  upon  this  basis, 
or  else  empirically  without  any  other  guide  than  chnical  experience, 
which  is  very  deceptive. 

MODIFICATION  WITH  THE  LACTIC  ACID  FERMENT.— 

This  method  of  modifying  milk  originated  from  the  same  idea  as  gave 
us  the  use  of  starch,  the  alkalies,  the  split  protein,  and  peptonization, 
namely  the  difficulty  in  digesting  the  large  tough  casein  curds  which 
are  formed  from  cow's  milk  during  the  process  of  gastric  digestion > 


Modification  of  Cow's  Milk  293 

When  the  lactic  acid  bacillus,  or  any  preparation  containing  its  active 
ferment,  is  added  to  cow's  milk,  part  of  the  lactose  is  by  fermentation 
converted  into  lactic  acid.  This  is  an  artificially  produced  souring 
of  the  milk,  much  like  the  natural  souring  which  takes  place  in  milk 
from  the  action  of  other  organisms  of  the  lactic-acid-forming  group 
normally  present  in  milk.  The  lactic  acid  bacillus  and  its  product 
are  known  to  be  harmless.  In  the  presence  of  the  lactic  acid  formed 
in  this  way,  the  casein  of  the  milk  is  precipitated  in  the  form  of  a 
curd  which  is  especially  finely  divided;  and  easily  digested.  There  is 
no  formation  of  large  curds  in  the  stomach,  and  lactic  acid  milk 
seems  to  be  relatively  quite  digestible. 

There  are  two  reasons  for  using  lactic  acid  milk  as  a  mere  feeding 
method.  One  is  that  described,  to  obtain  the  casein  already  pre- 
cipitated in  a  finely  divided,  and  easily  digested  form.  The  other 
is  that  lactic  acid  milk  is  relatively  low  in  carbohydrate  in  proportion 
to  the  protein,  and  may  be  useful  in  cases  in  which  carbohydrate  is  not 
well  tolerated. 

There  is  another  reason  for  using  lactic  acid  milk,  under  which  it 
is  not  strictly  a  resource  in  artificial  feeding.  This  use  is  based  on 
the  influence  of  the  lactic  acid  bacillus  on  certain  bacterial  processes 
in  the  intestine,  and  will  be  described  in  greater  detail  in  the  division 
on  the  gastro-intestinal  diseases.  To  meet  this  indication  it  is  neces- 
sary to  use  a  culture  of  the  lactic  acid  bacillus  of  known  anti-putrefac- 
tive power,  while,  if  lactic  acid  milk  is  used  simply  as  a  feeding  method, 
any  preparation  of  the  lactic  acid  bacillus  which  will  form  lactic  acid 
may  be  used. 

MODIFICATION  WITH  PRECIPITATED  CASEIN.— The  use 

of  precipitated  casein  in  infant  feeding,  is  to  be  traced  to  the  researches 
and  theories  of  Meyer  and  Finkelstein.  Their  original  theory  ascribed 
to  the  carbohydrate  of  cow's  milk,  the  lactose,  a  very  important  role 
in  the  production  of  severe  malnutrition  and  atrophy.  In  their  first 
publications,  lactose  was  considered  quite  deadly,  while  the  fats  and 
mineral  salts  were  not  absolved  from  partial  blame.  To  fit  their 
theory,  they  prepared  their  celebrated  "  Eiweiss  Milch,"  or  albumin 
milk.  The  only  new  feature  in  albumin  milk  was  the  use  of  precipi- 
tated casein. 

The  casein  is  precipitated  with  a  rennin  preparation,  washed, 
ground  fine  through  a  sieve,  and  then  is  added  to  some  food 
mixture.  The  idea  underlying  its  use  was  originally,  to  increase  the 
casein  content  of  the  food,  without  a  proportionate  increase  in  the 
lactose  or  mineral  salts.  It  has  been  found  recently  that  a  good 
part  of  the  mineral  salts  remain  with  the  casein  instead  of  going  out 
with  the  whey.  The  lactose,  however,  can  be  gotten  rid  of.  The 
casein  is  in  a  finely  divided  form,  which  is  probably  easy  of  digestion 


294  Feeding 

in  the  majority  of  cases.  The  use  of  precipitated  casein  does  not 
show  very  much  difference  in  its  probable  effect,  from  the  use  of  lactic 
acid  milk.  Only,  the  possible  benefit  from  the  anti-putrefactive 
properties  of  lactic  acid  milk,  is  not  to  be  expected  with  precipitated 
casein. 

THE  COOKING  OF  COW'S  MILK  MIXTURES.— The  effect 
of  the  cooking  of  cow's  milk  on  the  digestibility  of  the  milk  has  never 
been  determined.  There  is  some  evidence  that  cooking  makes  milk 
more  digestible,  other  evidence  that  it  makes  it  less  so.  Cooking  pro- 
duces certain  changes  in  the  chemistry  of  the  milk  which  are  known, 
but  the  relation  of  these  changes  to  digestion  has  never  been  estabhshed, 

Fig.  76 


Apparatus  for  homogenizing  fat  for  infant  feeding 

It  is  known  that  cooking  coagulates  the  lactalbumin,  precipitates 
some  of  the  mineral  salts,  and  produces  certain  chemical  changes  in 
the  casein.  These  changes  make  the  casein  less  coagulable,  and  the 
curd  formed  with  rennet  is  softer  and  finer  than  in  raw  milk.  On 
the  other  hand,  the  casein  curd  is  less  readily  acted  on  by  the  proteoly- 
tic ferments  of  gastric  digestion.  It  is  probable  that  in  some  cases, 
cooking  has  a  favorable  effect.  The  best  established  favorable  action 
of  cooking,  is  that  seen  in  cases  in  which  large  casein  curds  are  found 


Modification  of  Cow's  Milk  295 

in  the  stools  of  the  infant.     In  such  a  case,  the  trouble  may  often  be 
relieved  by  boiling  the  milk. 

HOMOGENIZED  MILK  MIXTURES.— This  is  a  very  recently 
advocated  method  of  modifying  cow's  milk.  It  is  based  on  the  fact 
that  many  of  the  most  serious  cases  of  atrophy  and  malnutrition  in 
infancy  have  been  shown  to  be  characterized  by  inabihty  to  digest 
and  absorb  the  cow's  milk  fat.  The  difference  in  chemistry  between 
the  fat  of  cow's  milk  and  of  human  milk  is  not  affected  by  any  of  the 
methods  of  modifying  milk  described  above.  The  homogenizer  is  a 
compHcated  and  expensive  apparatus  for  breaking  up  fat  into  the 
finest  molecules,  much  finer  than  the  emulsion  seen  in  milk.  This 
is  done  by  forcing  the  fat  through  the  apparatus  under  heavy  pressure. 
Other  fats  than  cow's  milk  fat  may  be  used,  and  thus  the  unfavorable 
chemistry  of  cow's  milk  fat  may  be  avoided.  Those  now  interested 
in  homogenized  milk  advocate  the  use  of  olive  oil,  which  is  added  to 
a  milk  mixture,  and  then  forced  through  the  apparatus.  The  olive 
oil  comes  out  in  a  form  so  finely  divided  as  to  be  supposedly  easy  of 
digestion. 

The  method  of  feeding  with  homogenized  milk  is  a  very  newly  sug- 
gested method,  and  its  possible  value  is  as  yet  unsupported  by 
conclusive  evidence.  If  it  be  shown  in  the  course  of  time  that  it  has 
a  value  in  infant  feeding,  its  use  will  probably  be  confined  to  cases 
of  very  resistant  difficulty,  with  inabihty  to  take  as  much  fat  as  they 
require. 

ALBUMIN  MILK.  (Protein  Milk;  Finkelstein's  Eiweiss 
Milch). — This  is  a  modification  of  cow's  milk  recommended  by  Fin- 
kelstein.  The  theory  underlying  its  use  was  originally  that  the  lactose 
in  cow's  milk  is  not  well  borne  in  certain  cases,  and  is  a  frequent  source 
of  difficulty  in  artificial  feeding.  The  original  object  of  Finkelstein's 
preparation  was  to  secure  a  food  which  was  low  in  lactose,  and  high 
in  protein.  The  most  definite  directions  were  given  as  to  the  prepara- 
tion of  this  food,  which  will  be  described  when  the  subject  of  home 
modification  is  discussed. 

Albumin  milk  is  essentially  a  combination  of  lactic  acid  milk  with 
precipitated  casein.  When  made  according  to  the  prescribed  direc- 
tions it  has  an  average  composition  of  about — 

Fat  2  .  50  Lactose  i .  50  Protein  3 .  00  Salts   .  50 

The  fat  percentage  is  rather  variable. 

Albumin  milk  was  recommended  to  meet  a  definite  theory  as  to 
the  etiology  of  chronic  gastro-intestinal  disease.  The  theory  has  been 
later  much  modified  and  changed.  In  particular,  the  original  theory 
held  that  the  lactose  in  cow's  milk  mixtures  is  one  of  the  most  frequent 
sources  of  danger.     This  has  not  been  corroborated  by  other  investi- 


296  1-EEDING 

gators.  That  lactose  may,  through  excessive  fermentation,  be  a 
cause  of  indigestion,  is  undoubtedly  a  fact,  but  that  it  is  a  serious 
disturber  of  metabolism,  giving  rise  to  intoxication,  is  probably  not 
true.  This  idea  was  probably  borrowed  by  Finkelstein  from  some 
work  published  by  Grosz,  later  elaborated  by  Langstein  and  Steinitz, 
on  sugar  elimination  in  the  urine  in  severe  cases  of  gastro-intestinal 
disorder.  It  has  been  contradicted  by  the  work  of  later  investiga- 
tors. While  there  may  be  cases  in  which  there  exists  an  intolerance 
of  sugar  sufficiently  severe  to  call  for  an  amount  of  sugar  in  the  food 
no  greater  than  that  in  albumin  milk,  it  is  probable  that  they  are  very 
rare,  and  do  not  explain  the  favorable  results  obtained  by  many  in- 
vestigators in  using  this  food. 

Another  theory  advanced  in  favor  of  the  value  of  albumin  milk, 
was  that  the  high  salt  content  of  cow's  milk  was  a  source  of  damage, 
and  that  in  the  precipitated  casein  used  in  making  Finkelstein's  food, 
the  salts  are  got  rid  of.  This  also  has  been  disproved.  It  has  been 
shown  that  much  of  the  mineral  matter  goes  over  with  the  casein, 
and  that  the  salt  content  of  albumin  milk  is  quantitatively  but  little 
diminished. 

The  principal  respects  other  than  the  low  proportion  of  lactose 
in  which  albumin  milk  differs  in  composition  from  an  ordinary  cow's 
milk  modification,  of  the  same  fat  and  protein  content,  is,  first,  that 
the  casein  is  precipitated  beforehand  in  a  very  finely  divided  form, 
and  second,  that  the  food  contains  lactic  acid.  The  favorable  results 
reported  from  its  use  must  be  due  to  one  or  both  of  these  features. 
That  both  features  are  of  value,  is  quite  probable.  That  lactic  acid 
milk  has  a  favorable  effect  on  certain  fermental  processes  in  the  intes- 
tine, has  been  fairly  well  established,  although  Finkelstein  entirely 
disregarded  this  as  a  possible  mode  of  action,  in  his  effort  to  fit  his 
food  to  his  theory.  There  is  also  evidence,  that  foods  containing  the 
casein  already  precipitated  in  a  finely  divided  form,  are  more  digestible 
in  certain  cases. 

It  must  be  remembered  that  the  evidence  on  which  the  value  of 
albumin  milk  in  infant  feeding  is  based,  is  of  the  highly  unreliable, 
statistical  kind,  obtained  by  feeding  a  series  of  babies  on  this  food, 
and  making  a  compilation  of  the  various  results  observed.  Almost 
any  method  of  feeding  investigated  in  this  way  will  give  favorable 
results.  The  method  of  studying  individual  cases,  under  conditions 
approaching  as  nearly  as  possible  those  of  an  experiment,  has  not 
been  employed.  No  great  effort  has  been  made  to  determine  whether 
either  of  the  two  principles  combined  in  albumin  milk,  namely,  lactic 
acid  fermentation,  and  the  addition  of  precipitated  casein,  will  not 
give  equally  good  results,  when  used  separately.  No  great  eff'ort 
has  been  made  to  determine  the  clinical  type  of  case  in  which  albumin 
milk  works  better  than  other  methods. 


Modification  of  Cow's  Milk  297 

That  each  of  the  two  principles  combined  in  albumin  milk  is  of 
great  value  in  certain  cases,  is  undoubtedly  true.  That  there  are 
cases  in  which  a  combination  of  these  two  principles,  as  realized  in 
albumin  milk,  is  the  best  method  of  feeding,  is  also  probable.  There- 
fore these  principles,  and  their  combination,  must  have  a  place  in 
artificial  feeding,  among  our  stock  of  resources.  What  is  the  exact 
indication  for  their  use  remains  to  be  determined. 

It  must  be  remembered  that  albumin  milk  being  so  widely  spoken 
of  as  a  food,  or  method  of  feeding,  there  is  danger  of  its  coming  to 
be  regarded  as  an  ideal  baby  food,  as  a  food  or  method  of  feeding  of 
superior  value  for  babies  in  general,  and  not  as  a  resource  to  be  used 
in  special  cases.  If  we  are  to  judge  by  the  precedents  of  other  widely 
advertised  methods  of  feeding,  there  is  danger  that  the  general  or 
indiscriminate  use  of  albumin  milk  may  do  harm  in  the  future.  This 
danger  is  now  heightened  by  the  fact  that  in  Europe  Finkelstein's 
albumin  milk  is  a  secret,  patent  preparation,  sold  by  a  manufacturing 
company  in  sealed  cans,  and  advertised  as  a  baby  food.  The  same 
company,  or  its  branch,  has  introduced  its  sale  into  this  country. 
It  is  true  that  we  know  enough  about  the  composition  of  albumin  milk 
to  order  its  preparation  in  our  homes  and  hospitals,  without  resorting 
to  the  patented  form.  Is  it  not  better,  however,  in  using  and  study- 
ing albumin  milk,  to  consider  chiefly  the  two  main  features  in  its 
composition,  and  to  order  them  separately,  or  in  combination?  We 
are  not  confined  to  making  albumin  milk  according  to  the  original 
formula,  but  may  combine  lactic  acid  milk  with  precipitated  casein 
in  any  proportions  we  see  fit.  We  can  thus  use  albumin  milk,  while 
avoiding  the  name,  and  will  not  be  perpetuating  the  idea  of  its  superior 
value  as  a  baby  food.  We  can  extend  our  investigations  as  to  its 
value,  by  combining  its  principles  with  varying  amounts  of  different 
sugars,  and  of  fat.  Like  all  other  methods  which  have  given  clinical 
evidence  of  good  results,  albumin  milk  or  the  principle  it  embodies, 
will  probably  in  the  end  occupy  its  definite  and  particular  place  among 
our  stock  of  resources. 

MALT  SOUP  MODIFICATION  OF  COW'S  MILK.— This  modi- 
fication of  cow's  milk  was  introduced  by  Keller,  as  a  food  to  be  used 
in  cases  of  difiicult  feeding.  Wheat  flour  is  cooked  in  the  milk,  and 
then  malt  extract  is  added,  and  the  whole  is  heated  for  about  five 
minutes.  This  food  has  given  clinical  evidence  that  in  certain  diffi- 
cult feeding  cases,  it  gives  better  results  than  ordinary  modifications. 
It  must  therefore  receive  a  place  among  our  stock  of  methods  of 
modifying  cow's  milk. 

Malt  soup  is  rich  in  carbohydrate.  Keller  believed  that  through 
its  use,  less  protein  was  lost  by  intestinal  fermentation,  but  this  has 
never  been  definitely  proved.     Malt  soup  is  essentially  a  combination 


298  Feeding 

of  three  methods  of  modifying  milk  already  described,  namely,  modifi- 
cation with  starch,  modification  with  maltose,  and  the  cooking  of  milk. 
Furthermore,  a  certain  amount  of  the  starch  is  dextrinized. 

We  have  seen  that  all  three  of  the  methods  of  modifying  combined 
in  malt  soup,  have  their  particular  favorable  action  on  the  digestion 
of  cow's  milk.  To  combine  them  is  probably  desirable  in  certain 
cases. 

The  dextrinization  of  the  starch  in  the  malt  soup  is  a  new  element. 
Dextrinization  has  been  advised  as  a  good  method  in  preparing  a  food 
for  infants,  and  dextrinized  gruels,  made  by  heating  a  cereal  decoction 
with  thick  malt  extract,  have  been  employed.  W£  have  no  essential 
facts  in  digestion  or  metabolism  to  support  their  use,  although  they 
may  have  a  value  in  certain  cases.  The  evidence  in  their  favor  is 
of  the  unreHable  clinical  variety.  It  seems  best  to  include  them  under 
malt  soup. 

HOW  THE  RESOURCES  OF  COW'S  MILK  MODIFICA- 
TION ARE  REALIZED  IN  PRACTICE 

Familiarity  with  the  various  principles  on  which  the  modification 
of  cow's  milk  is  based,  is  not  the  only  essential  in  the  intelligent  arti- 
ficial feeding  of  infants.  The  physician  must  know  exactly  how  he 
can  utilize  in  practice  the  various  methods  at  his  disposal,  so  that 
any  method  which  he  believes  to  be  indicated  in  an  individual  case 
may  be  employed. 

PREREQUISITES. — It  is  essential  that  the  physician  should  be 
able  to  utilize  the  resources  of  artificial  feeding  to  their  fullest  extent. 
It  is  undoubtedly  true  that  the  majority  of  babies  which  he  will  be 
called  upon  to  feed,  will  not  require  any  of  the  more  complicated 
methods  of  modifying  milk.  Simple  combinations  of  milk,  diluent, 
and  lactose,  are  all  that  is  required  in  these  cases.  Consequently,  many 
so-called  simplified  methods  of  feeding  babies  have  been  devised  and 
pubHshed,  which  give  the  impression  that  the  artificial  feeding  of 
babies  is  not  in  reahty  a  very  difficult  or  complicated  problem.  The 
success  of  such  simplified  methods,  when  judged  by  clinical  statistics, 
is  evident,  and  is  to  be  expected  from  the  comparatively  normal 
digestive  powers  of  the  majority  of  infants.  These  methods,  how- 
ever, as  is  well-known,  will  fail  to  solve  the  occasional  difficult  prob- 
lems which  arise.  Knowledge  of  the  methods  used  in  the  more 
difficult  cases  is  essential  to  their  proper  treatment,  and  does  not 
preclude  the  use  of  foods  of  simple  composition  in  comparatively 
normal  cases.  The  difficult  cases  are  numerous  enough  to  demon- 
strate that  the  problem  of  artificial  feeding  is  not  a  simple  one,  nor 
is  it  to  be  solved  by  simple  methods. 

We  must  assume  that  the  competent  physician  must  be  prepared 


Milk  Laboratories  299 

to  use  every  method.     Therefore  no  method  of  preparing  milk  modi- 
fications can  be  considered  which   does   not  fulfil   this  requirement. 

THE  PATENT  FOODS.— There  are  a  number  of  patent  infant 
foods  on  the  market,  which  embody  principles  known  to  be  of  value 
in  artificial  feeding.  Their  use  has  given  repeated  clinical  evidence 
of  the  special  value  of  some  one  of  them  in  certain  individual  cases. 
We  know  that  their  good  results  come  from  the  particular  principle, 
such  as  change  of  carbohydrate,  which  they  exemplify.  We  realize 
that  their  use  as  foods  for  babies  in  general  would  never  solve  the 
feeding  problem,  and  most  of  us  have  seen  how  great  is  the  harm 
done  by  their  indiscriminate  employment.  The  question  arises,  are 
we  not  justified  in  using  the  patent  foods,  not  indiscriminately,  not 
as  general  baby  foods,  but  intelligently,  in  a  particular  case  in  which 
we  believe  that  just  the  particular  modification  exemplified  by  the 
patent  food,  is  indicated.  Used  thus  inteUigently,  it  would  seem 
that  the  patent  food  would  do  no  harm,  and  it  may  be  the  most  con- 
venient means  of  realizing  the  particular  feeding  resource  which  we 
wish  to  employ. 

I  do  not  believe  we  are  justified  in  thus  using  the  patent  foods. 
Whatever  their  value  in  individual  cases,  the  fact  remains  that 
they  are  advertised,  and  sold  as  general  baby  foods.  As  long  as 
they  .are  thus  advertised,  their  use  cannot  but  help  to  perpetuate 
the  idea  that  they  are  baby  foods  of  superior  value.  Physicians 
should  avoid  perpetuating  this  harmful  idea.  Every  principle  ern- 
bodied  in  them  can  be  realized  without  their  use.  If  we  wish  to  use 
dextri-maltose,  it  is  better  to  use  some  preparation  advertised  merely 
as  a  specially  pure  form  of  dextri-maltose,  than  a  preparation  con- 
taining the  same  dextri-maltose  but  advertised  as  a  baby  food. 

MILK  LABORATORIES.— The  object  of  the  milk  laboratory  is 
to  aft'ord  to  the  physician  a  means  of  utilizing  every  known  method 
of  milk  modification  employed  in  infant  feeding.  In  this  busy  age 
of  scientific  rational  medicine  physicians  all  over  the  world  demand, 
first,  means  of  saving  time,  and  second,  exact  methods  of  work,  which 
in  themselves  soon  become  time-savers.  In  every  branch  of  our  art 
the  tendency  is  growing  year  by  year  to  systematize  the  detailed  and 
laborious  vv^ork  of  the  individual  for  the  common  practical  use  of  the 
profession  at  large.  The  two  chief  advantages  of  the  milk  labo- 
ratory are,  first,  the  saving  of  time  for  the  physician,  and  second, 
exactness  in  the  composition  of  the  foods  prepared  for  the  baby. 
The  physician's  time  is  saved  because,  thinking  of  his  food  in  terms 
of  the  percentages  of  the  various  food  elements  which  he  wishes  to 
give,  he  does  not  have  to  calculate  the  various  combinations  of  in- 
gredients which  will  give  the  required  food  composition,  nor  to  give 
to  nurse  or  mother  detailed  directions  for  the  preparation  of  the 


300  Feeding 

food.  This  is  done  at  the  laboratory.  Exactness  is  obtained  from 
the  fact  that  the  various  ingredients  used  in  preparing  the  food, 
such  as  cream,  milk,  barley  water,  and  so  forth,  are  standardized, 
and  contain  exactly  the  percentages  of  the  food  elements  demanded 
by  the  method  of  calculation  employed.  The  calculations  are  of 
course,  exact. 

In  using  the  milk  laboratory,  the  physician  writes  a  prescription, 
calling  for  any  food  which  he  wishes  to  give.  He  specifies  the  per- 
centages of  fat,  sugar,  and  protein  he  desires,  states  the  variety  of 
extra  sugar  to  be  used,  states,  if  he  wishes,  the  relative  quantities 
of  whey  protein  and  casein.  He  may  order  any  alkali  to  be  added, 
may  order  starch  in  any  amount,  may  have  the  food  fermented 
with  lactic  acid,  cooked,  pasteurized,  dextrinized,  or  peptonized.  He 
may  order  albumin  milk  or  precipitated  casein.  All  he  has  to  do 
is  to  specify  the  composition  of  the  food  he  wants,  and  the  labora- 
tory puts  up  this  food.  These  laboratories  have  been  placed  under 
the  control  of  educated,  intelligent  men  in  whom  we  should  have 
the  same  confidence  that  we  have  conceded  to  the  pharmacist,  and 
we  can  write  directions  for  infants'  foods  and  send  them  to  these 
laboratories  just  as,  in  the  treatment  of  disease,  we  write  our  pre 
scriptions  for  the  division  of  one  drug  or  the  combination  of  several. 
As  the  pharmacist  has  nothing  to  do  with  the  various  methods  of 
treating  disease,  so  the  milk-modifier  is  simply  required  to  carry 
out  the  directions  and  ideas  of  the  physician,  and  the  laboratory 
assumes  no  responsibiHty  as  to  the  success  or  failure  of  the  food. 
The  result  attained  depends  wholly  upon  the  physician's  intelligence 
in  the  use  of  the  resources  of  feeding. 

In  addition  to  carrying  out  the  physicians'  prescription  calling  for 
a  food  of  a  certain  composition,  the  milk  laboratory  provides  a  good 
and  clean  milk  supply,  and  the  modification  and  dehvery  of  the 
milk  is  carried  on  under  the  cleanest  conditions. 

To  illustrate  the  use  of  the  laboratory,  a  prescription  blank  from 
the  Walker-Gordon  Laboratory  is  reproduced  on  the  opposite  page: 
It  will  be  seen  how  all  the  more  ordinary  milk  modifications  can  be 
ordered  very  simply  from  these  blanks.  For  some  more  compli- 
cated preparations,  the  physician  must  give  a  more  detailed  descrip- 
tion of  what  he  wants. 

The  filled  prescription  calls  for  a  food  having  a  fat  percentage 
of  2,  a  sugar  percentage  of  6,  the  extra  sugar  being  maltose,  a  whey 
protein  percentage  of  .75,  and  a  casein  percentage  of  .50.  Lime 
water  is  to  be  added  in  the  amount  of  20  per  cent  of  the  milk  and 
cream.  The  food  is  to  be  pasteurized  at  145°  F.,  and  delivered 
in  eight  feeding  bottles,  each  containing  six  ounces. 

The  prescription  blank  is  arranged  for  the  use  of  all  the  more 
ordinary  resources  of  infant  feeding.     When  the  physician  wishes 


Home  Modification 


301 


Fig.  77 
WALKER-GORDON  LABORATORIES 


Fats. 


I  Lactose  (Milk  Sugar') 
Maltose  (Malt  Sugar) 
Sucrose  (Cane  Sugar) 
Dextrose(Grape  Sugar) 
I  Starch 


(b)  Dextrinize. 

(c)  Proteids... 

(d)  Peptonize. 


fWhey.. 
Casein. 


(e)   Sodium  Citrate 


(f)    Sodium  Bicarb, 


(g)  Lime  Water. . . 


(h) 


%  of  milk  and  cream. , 
%  of  total  mixture. . .  . 
%  of  milk  and  cream. 
%  of  total  mixture. . .  , 
%  of  milk  and  cream. 
%  of  total  mixture. . . 


[  1 — To    inhibit    the    sapro- 
Lactic  Acid  phy tes  of  fermentation 


Bacillus 


2 — To  facilitate  digestion  of 
[  the  proteids 


Per  Cent 
2 


Heat  at 145°F. 

Number  of  Feedings 8. . . 

Amount  at  each  Feeding 6 . . . 

ORDERED  FOR 


Address 

Date 19. 


Note — See  back  of  pad. 


.  ...M.  D. 
(Over) 


EXPLANATORY 


(a)  It  requires  .75  per  cent  starch 
to  make  the  precipitated  casein  finer. 

(b)  One  hour  completely  dextrinizes  . 
the  Starch. 

(c)  In  case  physicians  do  not  wish 
to  sub-divide  the  proteids,  the  words 
"Whey"  and  "Casein"  may  be  erased. 

(d)  Twenty  minutes  renders  the 
mixture  decidedly  bitter. 

(e)  It  requires  0.20%  of  the  milk 
and  cream  used  in  modifying  to  facili- 
tate the  digestion  of  the  proteids; 
i.  e.,  the  formation  of  a  soft  curd. 
0.40%  to  prevent  the  action  of  rennet; 
i.  e.,  the  formation  of  tough  curd. 

(f)  It  requires  .68%  of  the  milk  and 
cream  used  in  modifying  to  favor  the 
digestion  of  the  proteids.  1.70%  of 
the  amount  of  milk  and  cream  used 
suspends  all  action  on  the  proteids  in 
the  stomach.  1.7%  of  the  total  mix- 
ture gives  a  mild  alkaline  food. 

(g)  It  requires  20%  of  the  milk 
and  cream  used  in  modifying  to  favor 
the  digestion  of  the  proteids.  50%  of 
the  amount  of  milk  and  cream  used 
suspends  all  action  on  the  proteids  in 
the  stomach.  5%  of  the  total  mix- 
ture gives  a  mild  alkaline  food. 

(h)  Percentage  figures  represent  the 
per  cent  of  Lactic  Acid  attained  when 
the  food  is  removed  from  the  thermo- 
stat. When  the  Lactic  Acid  Bacillus 
is  used  to  facilitate  digestion  of  the 
proteids,  this  is  the  final  acidity,  as 
the  process  is  stopped  by  heat  at  this 
point.  When  the  Lactic  Acid  Bacillus 
is  used  to  inhibit  the  growth  of  sapro- 
phytes, the  acidity  may  subsequently 
increase  to  a  variable  degree,  as  the 
bacilli  are  left  alive.  .25%  Lactic  Acid 
just  curdles  milk.  .50%  gives  thick 
curdled  milk.  .75%  separates  into 
curds  and  whey. 

Walker-Gordon  Laboratories 

1106  Boylston  Street 

Boston 

And  all  Large  Cities 


to  use  certain  special  methods  of  modifying  milk,  such  as  albumin 
milk,  modification  with  precipitated  casein,  malt  soup  mixtures,  and 
homogenized  fat  mixtures,  he  must  transmit  to  the  laboratory  more 
specific  directions  as  to  what  he  wants.  The  laboratory  is  prepared 
to  carry  out  any  wishes  of  the  physician  in  regard  to  the  modification 
of  cow's  milk  for  infant  feeding. 

HOME  MODIFICATION.— In  many  cases,  probably  the  major- 
ity, a  milk  laboratory  cannot  be  utilized  to  obtain  the  desired  milk 
modifications  for  the  infant.  In  these  cases  the  food  has  to  be  pre- 
pared at  home,  by  the  nurse  or  mother.  To  be  successful  in  all 
cases,  the  physician  must  be  able  to  utilize  by  home  modification, 
all  the  methods  of  milk  modification  available  in  artificial  feeding. 
This  can  be  done,  with  less  accuracy  than  at  the  laboratory,  but  with 


302  Feeding 

sufficient  accuracy  for  practical  purposes.  All  the  methods  of  modi- 
fying milk  described  here  except  homogenization  can  be  carried  out 
at  home,  although  some  of  them  are  rather  troublesome  and  labori- 
ous, and  in  some  cases,  the  widest  extremes  of  percentages  cannot 
be  obtained. 

TECHNIQUE  OF  HOME  MODIFICATION 
The  following  implements  are  required: — As  many  feeding  bottles 
as  there  are  feedings  in  twenty-four  hours;  the  milk,  in  quart  jars; 

Fig.  78 


^^S:,.  ^  „  -  i; .  -V  ;.•    ^ 

Home  modification  of  cow's  milk.     Apparatus 

lactose  or  other  carbohydrate;  a  pitcher  large  enough  to  hold  the 
whole  of  the  mixture;  an  empty  quart  milk  jar;  a  graduate,  holding 
one  pint;  a  tablespoon;  a  teaspoon;  sterile  cotton  or  albumin  caps 
to  stopper  the  bottles;  a  cream  dipper.  All  the  implements  should 
be  clean,  and  sterilized  by  boihng. 

The  lactose  is  measured  with  a  tablespoon,  put  in  the  empty  milk 
jar,  and  the  boiled  water  measured  in  the  graduate  is  added  while 
still  hot.  The  jar  is  then  shaken  until  the  lactose  is  dissolved,  and 
put  aside  to  cool.  The  top  ounce  of  cream  is  removed  with  a  tea- 
spoon, to  allow  the  insertion  of  the  cream  dipper  without  overflow. 
The  rest  of  the  cream,  down  to  the  cream  line,  is  removed  with  the 


Home  Modification 


303 


cream  dipper,  and  put  into  the  graduate.  The  excess  of  cream  in  the 
graduate  is  poured  off,  leaving  in  the  graduate  only  the  quantity  of 
cream  required  by  the  formula.*  This  is  then  placed  in  the  pitcher. 
The  skimmed  milk  remaining  in  the  milk  jar  is  mixed  by  shaking, 
and  the  quantity  required  is  measured  off  in  the  graduate,  and  added 
to  the  pitcher.  When  cool,  the  boiled  water  and  lactose  are  poured 
into  the  pitcher.  The  quantities  to  be  given  at  each  feeding  are 
measured  off  in  the  graduate,  and  placed  in  the  feeding  bottles.    The 


Fig.  79 


Home  modification  of  cow's  milk.     Obtaining  the  cream 

bottles  are  stoppered,  and  are  then  pasteurized,  if  pasteurization  is 
to  be  used.  (See  technique  of  pasteurization,  p.  274.)  The  bottles 
are  finally  placed  on  ice,  until  used,  when  each  bottle  is  warmed  and 
given  to  the  baby. 


THE  CALCULATION  OF  HOME  MODIFICATION 

The  physician  using  home  modification,  thinks  of  the  food  he 
wishes  to  give  in  the  general  terminology  of  the  percentages  of  its 
component  elements.  He  must  be  able  to  translate  this  percentage 
formula  into  definite  directions   for  obtaining  and  mixing  certain 

*  If  the  amount  of  cream  obtained  from  one  quart  is  less  than  the  amount  required 
in  the  formula,  two  quarts  must  be  used  in  obtaining  the  cream. 


304 


Feeding 


ingredients.  This  involves  a  certain  amount  of  mathematical  cal- 
culation. A  great  variety  of  methods  of  calculating  have  been 
devised  and  pubhshed.  Some  of  them  have  a  certain  time-sa\dng 
merit,  but  most  of  the  abbreviated  methods  are  difficult  to  remember, 
if  not  in  constant  use.  The  method  given  here  is  based  on  the 
fundamental  mathematical  principle  involved,  from  which  all  abbre- 
viated methods  are  derived.     Once  learned,  it  is  not  forgotten. 


Fig.  So 


Home  modification  of  cow's  milk.     ^li.xing  the  ingredients 


Milk  and  Cream  Dilution  with  the  Addition  of  ]\Iilk  Sugar. — 
This  is  the  fundamental  method  by  which  we  vary  at  will  the  per- 
centages of  the  three  principal  food  elements,  the  fat,  sugar,  and  pro- 
tein. Certain  ingredients  are  obtained,  and  we  must  calculate  the 
number  of  ounces  of  each  one,  which  must  be  diluted  with  water  to 
produce  the  required  food. 

To  simplify  the  calculations,  we  assume  a  definite  composition  for 
the  ingredients  used.  The  formulae  thus  assumed  are  by  no  means 
accurate,  but  the  calculation  of  home  modifications  may  be  suffi- 
ciently simplified  to  avoid  very  troublesome  fractions,  and  to  shorten 
the  process  of  calculation,  provided  that  the  error  be  not  too  great. 
The  actual  average  composition  of  the  milk  ingredients  most  com- 
monly used  in  home  modification  is  shown  in  the  table. 


LACTOSE 

PROTEIN 

4-75 

3-50 

4 

45 

327 

4 

20 

305 

3 

40 

2.50 

5 

CXD 

3-55 

5 

00 

3 -65 

5 

10 

0.90 

Home  Modification  305 

Table  31 
Average  Composition  of  the  Milk  Ingredients  Used  in  Home  Modification 

FAT 

Whole  milk 4  ■  00 

10%  cream 10. 00 

16%  cream 16.00 

32%  cream 32 .  00 

Skimmed  milk i .  00 

Separated  milk  ("fat  free") .25 

Wliey 25 

The  ingredients  used  are  the  following: — 

1.  Gravity  cream,  which  is  obtained  by  taking  off  with  a  cream 
dipper  from  a  quart  jar  of  milk  all  the  cream  which  rises  after  eight 
or  more  hours'  standing. 

2.  Skimmed  milk,  which  is  the  milk  left  in  the  jar  after  all  the 
cream  has  been  removed. 

3.  Dry  milk  sugar. 

For  purposes  of  calculation,  we  assume  the  following  composition 
for  these  ingredients: 

FAT  LACTOSE        PROTEIN 

Gravitj' cream 16.00  4.50  3.20 

Skimm'ed  milk 0.00  4.50  3.20 

Dry  lactose 0.00         100.00  0.00 

The  calculation  is  based  on  a  fundamental  mathematical  propor- 
tion, by  which  all  problems  in  dilution  may  be  solved.  The  pro- 
portion is  as  follows: 

The  quantity  of  an  ingredient  : 
The  total  quantity  o '  the  mixture  = 
The  per  cent  of  any  element  in  the  ingredient: 
The  per  cent  of  that  element  in  the  mixture. 
If  this  is  expressed  in  algebraic  terms, — 
Let  X  represent  the  ounces  of  the  ingredient  (ounces  required). 
Let  a  represent  the  total  ounces  of  food  desired. 
Let  m  represent  the  per  cent  of  any  element  in  the  mixture  (per 

cent  required). 
Let  n  represent  the  per  cent  of  that  element  in  the  ingredient  (16% 
for  fat;  3.20%  for  protein;  4.50%  for  lactose). 

Then     .v  :  a  =  m  :  n 
m 

X  = X  a  . 

n 

The  ounces  of  an  ingredient  required  to  give  a  certain  percentage 
is  found  by  dividing  the  percentage  required  by  the  percentage  of  the 
element  in  the  ingredient,  and  multiplying  by  the  total  number  of  ounces 
in  the  mixture.  Or  the  percentage  required  may  first  be  multiplied 
by  the  total  number  of  ounces  in  the  mixture,  and  then  divided  by 
the  per  cent  of  the  element  in  the  ingredient. 

20 


306  Feeding 

For  example,  suppose  we  wish  to  calculate  the  home  modification 
of  a  food  containing — 

Fat  3  Lactose  6  Protein  2 

the  baby  to  have  8  feedings,  of  4  ounces  each — 
The  total  mixture,  a,  is  32  ounces,  the  percentage  of  fat  required, 
m,  is  3,  and  as  always,  the  percentage  of  fat  in  our  first  ingredient, 
gravity  cream,  is  16, 

3 

X  = X  32  =  6  ounces  of  cream. 

16 

Protein  is  contained  in  both  the  cream  and  the  skimmed  milk, 
and  is  assumed  to  have  the  same  percentage  in  each,  namely  3.20. 
The  percentage  of  protein  required  being  2.00, 

2 

X  = X  32  =  20  ounces  of  cream  and  skimmed  milk. 


3.20 

The  cream  having  been  already  determined  as  6  ounces,  the  skimmed 
milk  must  be — 

20  —  6  ounces,  or  14  ounces. 

Before  determining  the  amount  of  dry  lactose  needed  to  bring  the 

lactose  percentage  up  to  the  required  6%,  we  must  determine  what 

percentage  of  lactose  is  added  by  the  milk  and  cream.     The  same 

formula — 

X  :  a=^m  :n 

is  used,  but  now  x,  the  number  of  ounces  of  the  ingredient. is  known, 
the  unknown  quantity  being  m,  the  percentage  of  lactose  in  the 
mixture  after  dilution  of  the  cream  and  skimmed  milk — 

If     X  :  a^  m  :  n 

m  = X  n 

a 

The  percentage  given  by  diluting  an  ingredient  is  found  by  dividing 
the  ounces  of  the  ingredient  used,  by  the  total  ounces  in  the  mixture, 
and  multiplying  by  the  percentage  of  the  element  in  the  ingredient. 
Therefore : — 

20  5  9  45  .  ,      .  „ 

m  = X  4-  50  = X =  - —  =  3  approximately,  1.  e.,  3  Vo. 

32  .  8  2  16 

To  determine  the  ounces  of  dry  lactose  needed  to  give  the  additional 
required  sugar  percentage  of  3,  we  use  the  original  form  of  the  pro- 
portion, the  percentage  of  sugar  in  dry  lactose  being,  of  course,  100, 

3 
X  = X  32  =  .96  or  approximately,  i  ounce. 

100 


Home  Modification  307 

In  home  modification  it  is  troublesome  to  require  the  nurse  or  mother 
to  weigh  the  sugar  on  a  scale.  The  common  domestic  measure,  the 
tablespoon,  is  usually  employed.  As  a  basis  of  calculation,  we 
consider  that, 

2  rounded  tablespoonfuls  of  sugar  =  i  ounce. 

A  rounded  tablespoon  is  obtained  by  gently  shaking  a  heaping  table- 
spoon, until  the  extra  sugar  has  fallen  off.  In  our  calculation,  the 
sugar  required  being  one  ounce,  we  would  in  our  directions  call  for 
two  rounded  tablespoons. 

The  complete  directions  which  we  would  issue  to  the  mother  would 
be  as  follows: 

From  a  quart  jar  of  milk,  on  which  the  cream  has  "set"  (after 
eight  or  more  hours'  standing),  remove  with  a  cream  dipper  all  the 
cream  down  to  the  "cream  line."  This  is  "gravity  cream."  The 
milk  left  in  the  jar  mixed  by  shaking  is  skimmed  milk.     Mix  as  follows : 

Gravity  cream,  6  ounces 
Skimmed  milk,  14  ounces 
Boiled  water,  12  ounces 
Milk  sugar,  2  rounded  tablespoons 

The  milk  sugar  should  always  be  dissolved  first  in  the  boiled  water 
while  the  latter  is  still  hot. 

The  steps  in  the  process  may  be  summarized  as  follows: — - 

1.  Determine  the  ounces  of  cream  needed  to  give  the  required 
fat  percentage  (calculation  of  x).  Divide  the  percentage  of  fat 
required  by  16  and  multiply  by  the  total  number  of  ounces  in  the 
mixture. 

2.  Determine  the  ounces  of  cream  plus  milk  needed  to  give  the 
required  protein  percentage  (calculation  of  x).  Divide  the  percent- 
age of  protein  required  by  3.20  and  multiply  by  the  total  number 
of  ounces  in  the  mixture. 

3.  To  determine  the  ounces  of  skimmed  milk  needed,  subtract 
the  ounces  of  cream  used  from  the  ounces  of  cream  plus  milk. 

4.  Determine  the  percentage  of  sugar  given  by  diluting  the  cream 
and  milk  (calculation  of  m).  Divide  the  ounces  of  cream  and  milk 
by  the  total  number  of  ounces  in  the  mixture,  and  multiply  by  4.50. 
Subtract  this  from  the  percentage  of  sugar  required,  to  find  the 
additional  sugar  percentage  needed. 

5.  Determine  the  ounces  of  milk  sugar  required  to  give  the  addi- 
tional sugar  percentage  required  (calculation  of  x).  Divide  the  ad- 
ditional sugar  percentage  required  by  100  and  multiply  by  the  total 
number  of  ounces  in  the  mixture. 

6.  Reduce  the  sugar  from  ounces  to  rounded  tablespoons  by  mul- 
tiplying by  2. 


308  Feeding 

Suppose  now  we  wish  to  calculate  the  following  formula — 

Fat  2  Lactose  7  Protein  1.50 

the  baby  to  have  8  feedings  of  5  ounces  each. 

The  steps  as  enumerated  above,  would  be  as  follows: 

2 

1.     X  40  =  5  ouncesgravity  cream. 

16 

1.5  1-5 

2.    X  40  :^ =  18 . 7,  or  19  ounces  cream  and  milk. 

3.20  . 08 

3.  19  —  5  ^  14  ounces  skim.med  milk. 

19  19  9  178 

4.  - —  X  4.50  = X  —  = =2.22,  or  2%  sugar  added  by  the 

40  40  2  80 

cream  and  milk.     7  —  2  =  5%  additional  sugar  required. 

5  .     ■  .  ■ 

5.     X  40  =  2  ounces  of  dry  milk  sugar  required. 

100 

6.  2X2  =  4  tablespoons  dry  milk  sugar  required. 

Omitting  the  preliminary  directions  for  obtaining  the  ingredients, 
the  directions  would  be  as  follows: 

Gravity  cream,  5  ounces 
Skimmed  milk,  14  ounces 
Boiled  water,  21  ounces 
Milk  sugar,  4  tablespoons 

It  is  necessary  at  times  to  eliminate  various  troublesome  frac- 
tions of  ounces  or  percentages  which  occur  during  the  calculation. 
The  error  involved  in  thus  eliminating  fractions  is  not  very  great, 
and  the  various  errors  are  very  apt  to  offset  one  another.  It  is 
best  to  have  some  definite  rule  of  procedure  in  eliminating  fractions. 
The  following  is  a  good  rule: — With  fractions  involving  percentage 
of  fat  or  ounces  of  cream,  take  the  nearest  quarter  per  cent  or  quarter 
ounce;  with  fractions  involving  percentage  of  lactose  or  protein,  or 
ounces  of  skimmed  milk  or  milk  sugar,  take  the  nearest  half  per 
cent  or  half  ounce. 

Troublesome  fractions  may  also  be  eliminated  automatically,  if 
we  take  for  our  total  mixture  required  some  figure  easily  divisible 
by  other  numbers.  For  instance,  if  we  wish  to  give  7  feedings  of 
4  ounces  each,  we  can  take  for  our  total  mixture  32  ounces,  instead 
of  28.  There  will  only  be  a  waste  of  4  ounces,  and  the  figure  32 
is  much  easier  to  handle  in  calculating.  Similarly,  if  we  wish  to 
give  to  the  baby  7  feedings  of  5  ounces  each,  we  can  calculate  for 
a  mixture  of  40  ounces  instead  of  35,  with  a  waste  of  only  5  ounces. 

This  use  of  round  numbers  has  the  additional  advantage  that  it 
provides  extra  milk  to  allow  for  spilling  or  other  accident. 


Home  Modification  309 

There  are  two  ways  of  varying  the  relation  of  protein  to  fat  per- 
centage. We  may  choose  for  dilution  creams  of  different  fat  per- 
centages, each  having  a  different  proportion  of  protein  to  fat.  Or 
we  may  choose  for  dilution  a  cream  of  maximum  fat  percentage, 
having  the  lowest  proportion  of  protein  to  fat,  and  may  then  vary 
the  percentage  of  protein  by  adding  varying  amounts  of  fat-free 
(skimmed)  milk.  The  former  way  has  the  advantage  that  the  mother 
or  nurse  is  required  to  work  with  fewer  ingredients,  but  the  latter 
way  is  preferable.  Creams  of  different  fat  percentages  are  obtained 
by  taking  from  the  top  of  the  milk  a  various  number  of  ounces  after 
a  various  number  of  hours'  standing.  In  home  modification,  there 
is  always  an  error,  due  to  the  variations  in  cow's  milk,  so  that  our 
ingredients  never  represent  the  exact  percentages  which  we  assume 
to  be  their  composition.  The  most  essential  thing  in  home  modifica- 
tion is,  not  that  the  food  shall  contain  the  exact  percentages  that 
we  wish,  but  rather,  when  we  change  the  food,  that  the  new  food 
shall  bear  an  exact  relation  to  the  old  one.  If  we  are  constantly 
changing  our  method  of  obtaining  our  ingredients,  this  unknown 
initial  error  comes  in  all  over  again  with  each  change  of  food.  If 
we  work  with  two  constant  ingredients,  always  obtained  in  the  same 
way,  the  error  is  constant,  and  no  new  error  is  introduced.  Fur- 
thermore, it  has  been  found  that  the  gravity  cream  obtained  by  the 
method  described  of  removing  all  the  cream  down  to  the  cream  line, 
is  more  apt  to  be  close  to  the  assumed  fat  percentage,  and  is  less 
subject  to  variations,  than  creams  of  other  fat  percentages  obtained 
in  different  ways.  Another  advantage  of  using  the  ingredients  de- 
scribed here,  is  that  they  are  constant,  and  the  directions  for  obtain- 
ing the  ingredients  when  once  given  to  the  mother  or  nurse,  hold 
for  all  formulae  in  milk  and  cream  dilution,  and  do  not  have  to  be 
changed  or  repeated  when  the  composition  of  the  food  is  changed. 

The  Calculation  of  Starch. — Barley  water  is  the  usual  ingre- 
dient used  to  modify  cow's  milk  with  a  solution  of  starch.  The 
percentage  of  starch  in  barley  water  varies  according  to  the  manner 
in  which  the  barley  water  is  made.  Barley  water  made  according 
to  the  directions  accompanying  most  of  the  barley  flour  prepara- 
tions on  the  market,  contains  about  1.50  per  cent  of  starch.  As  the 
minimum  percentage  of  starch  required  in  a  milk  modification  to 
give  at  its  best  the  colloidal  action  of  the  starch  is  .75  per  cent,  it  is 
obvious  that  if  a  barley  water  containing  1.50  per  cent  of  starch  be 
used  as  the  ingredient,  half  the  mixture  must  be  barley  water.  As  a 
protein  of  1.60  per  cent  requires  half  the  mixture  to  be  milk  and 
cream,  we  cannot  have  half  our  mixture  barley  water  with  a  pro- 
tein percentage  higher  than  1.60.  As  we  frequently  wish  to  order 
a  higher  protein  than  this,  it  is  better  to  use  as  our  stock  ingredient 
a  barley  water  having  a  starch  percentage  of  3. 


310  Feeding 

Such  a  barley  water  may  be  obtained  from  any  of  the  barley  flour 
preparations,  by  giving  to  the  mother  or  nurse  the  following  direc- 
tions:— To  one  pint  of  water  add  two  level  tablespoons  of  barley 
flour;  boil  for  twenty  minutes;  replace  the  water  boiled  away  with 
enough  water  to  make  up  the  full  pint;  strain  through  three  layers 
of  cheese  cloth. 

The  calculation  is  very  simple,  the  same  formula 


being  used,  as  for  milk  and  cream,  n  being  3. 

If  we  want  a  .75  per  cent  starch  solution,  in  a  3 2 -ounce  mixture, 

•  75 
X  = X  32  =  8  ounces  of  barley  water. 

3 

It  is  easier  to  remember  that  if  we  are  working  with  a  barley  water 
containing  3  per  cent  of  starch,  and  if  we  desire  .75  per  cent  of  starch 
in  our  mixture,  one-quarter  of  the  total  mixture  must  be  barley 
water. 

The  Calculation  of  the  Alkalies. — As  shown  above,  the  alka- 
lies should  usually  be  prescribed  in  definite  relation  to  the  number 
of  ounces  of  milk  and  cream  in  the  mixture.  If  we  wish  to  use  lime 
water  in  the  amount  of  20  per  cent  of  the  milk  and  cream,  we  divide 
the  ounces  of  milk  and  cream  by  5,  to  obtain  the  ounces  of  lime 
water  required  in  the  mixture.  If  we  wish  to  use  lime  water  in  the 
amount  of  50  per  cent  of  the  milk  and  cream,  we  divide  the  ounces 
of  milk  and  cream  by  2.  It  must  be  remembered  that  lime  water, 
being  a  Hquid,  and  not  a  dissolved  dry,  ingredient,  enters  into  the 
total  mixture,  and  the  boiled  water,  or  other  diluent  must  be  pro- 
portionately diminished. 

In  the  case  of  the  other  alkalies,  the  calculation  is  as  follows  :^j 
Divide  the  figure  representing  the  percentage  of  sodium  bicarbonate 
or  sodium  citrate  required  by  100,  and  multiply  by  the  ounces  of 
milk  and  cream  in  the  mixture.  This  gives  the  alkali  required  in 
fractions  of  an  ounce.  To  reduce  to  drachms  multiply  by  8,  and 
to  reduce  this  to  grains,  multiply  the  result  in  drachms  by  60. 

For  example,  in  a  formula  requiring  5  ounces  of  cream  and  13 
ounces  of  skimmed  milk,  it  is  desired  to  add  sodium  bicarbonate 
to  delay  curd  formation  in  the  stomach,  and  to  alter  the  composi- 
tion of  the  curd.  The  amount  of  alkali  required  for  this  purpose 
is  .68  per  cent. 

Then     .68  -4-  100=  .0068. 

.0068  X  18=  .1184  ounces. 
.1184  X  8=  .9472  drachms. 
.9472  X  60=  56.8320  or  57  grains. 

approximately  one  teaspoonful. 


Home  Modification  311 

As  an  example  of  the  calculation  of  both  starch  and  alkali,  let 
us  suppose  that  in  the  formula  calculated  on  p.  308,  we  desired  to 
give  .75  per  cent  of  starch,  and  enough  lime  water  to  prevent  pre- 
cipitation of  the  protein  in  the  stomach.  The  usual  directions  would 
be  given  for  obtaining  gravity  cream  and  skimmed  milk.  Further 
directions  would  be  given  for  making  a  barley  water  containing  3 
per  cent  of  starch.     The  mixing  directions  would  be  as  follows — 

Gravity  cream,    5    ounces 
Skimmed  milk,  14    ounces 
Barley  water,      10    ounces 
*  Lime  water,  9I  ounces 

Boiled  water,        i|  ounces 
Milk  sugar,  4    tablespoons 

The  Technique  oe  Peptonization. — Pancreatine  (Extractum 
pancreatis)  is  an  official  preparation.  It  acts  only  in  an  alkaline 
medium,  and  the  amount  required  varies  with  the  protein,  and 
hence  with  the  ounces  of  milk  and  cream  in  the  mixture.  For  each 
ounce  of  milk  or  cream  in  the  mixture,  we  should  use  1/2  a  grain 
of  pancreatic  extract,  and  2  grains  of  sodium  bicarbonate.  There 
are  various  commercial  pancreatic  preparations  usually  in  the  form 
of  pastes  put  up  in  tubes,  and  usually  called  peptonizing  tubes. 
These  are  very  convenient,  and  as  the  directions  as  to  the  quantity 
accompanying  them  apply  to  whole  milk,  the  determination  of  the 
amount  required  in  dilutions  of  milk  and  cream  is  easy.  They  do 
not  require  the  addition  of  bicarbonate  of  soda. 

The  extract  and  sodium  bicarbonate,  or  the  paste,  is  dissolved 
in  about  4  ounces  of  the  boiled  water,  which  has  been  allowed  to 
cool.  This  is  then  added  to  the  milk  mixture,  which,  in  its  jar,  is 
set  in  a  vessel  of  water  at  a  temperature  of  107°  F,  The  time  varies 
according  to  the  degree  of  peptonization  desired.  The  usual  time 
is  from  seven  to  ten  minutes. 

Calculation  of  Whey  Mixtures. — The  calculation  of  spHt  pro- 
tein formulae  is  much  like  the  calculation  of  milk  and  cream  dilu- 
tions, except  that  a  new  food  element,  the  whey  protein,  enters  into 
consideration,  and  an  additional  ingredient,  whey,  is  used.  In  the 
instructions  given  to  the  mother  or  nurse,  in  addition  to  the  direc- 
tions for  obtaining  gravity  cream  and  skimmed  milk,  we  must  give 
the  necessary  directions  for  obtaining  whey.     They  are  as  follows: — 

To  make  the  whey,  use  skimmed  milk.  Add  Hquid  rennet,  or 
essence  of  pepsin,  or  a  junket  tablet  in  the  proportions  of  two  tea- 
spoons or  one  tablet  to  the  pint.  Warm  to  about  body  tempera- 
ture (100°  F.)  and  let  stand  until  the  curd  has  soHdified.  Break  up 
the  curd  with  a  fork  or  spoon,  and  strain  three  times  through  cloth 
or  fine  cheese  cloth.  Then  heat  the  whey  to  150°  F.  to  kill  the 
active  rennin. 


312  Feeding 

The  average  actual  percentage  formula  of  whey  is — 

Fat  o.  25  Lactose  5.  to  Whey  protein  0.90  Casein  0.00 

For  purposes  of  calculation,   the  formula  is  assumed  to  be — 

Fat  0.00  Lactose  4.50  Whey  protein  i . 00  Casein  0.00 

A  further  assumption  is  made  for  the  purpose  of  simplifying  the 
calculation.  A  certain  proportion  of  the  protein  of  cow's  milk  is 
whey  protein,  this  proportion  lying  between  one-fifth  and  one-fourth 
of  the  total  protein.  If  this  fact  were  taken  into  consideration  in 
the  calculation  of  whey  mixtures  for  home  modification,  the  mathe- 
matical diflaculties  would  be  much  increased.  The  small  propor- 
tion of  whey  protein  is  disregarded,  and  it  is  assumed  that  all  the 
protein  added  by  the  milk  and  cream  is  casein.  The  error  involved 
in  this  assumption  is  not  very  great,  and  is  partly  offset  by  the  assump- 
tion that  the  whey  protein  percentage  in  whey  is  i.oo  instead  of  0.90. 

The  various  steps  in  the  calculation  of  split  protein  formulae  are 
the  following: 

1.  Determine  the  ounces  of  cream  needed  to  give  the  required 
fat  percentage  (calculation  of  x).  Divide  the  percentage  of  fat 
required  by  16  and  multiply  by  the  total  number  of  ounces  in  the 
mixture. 

2.  Determine  the  per  cent  of  protein  contained  in  this  cream 
dilution  (calculation  of  m).  Divide  the  ounces  of  cream  by  the 
total  number  of  ounces  in  the  mixture,  and  multiply  b}^  3.20.  This 
protein  is  considered  as  being  all  casein,  and  represents  the  minimum 
casein  which  can  be  obtained.  If  the  percentage  of  casein  desired 
is  below  this  minimum,  the  formula  desired  should  be  readjusted 
to  require  the  minimum  obtainable  casein. 

3.  This  third  step  is  omitted,  unless  the  per  cent  of  casein  con- 
tained in  the  cream  is  lower  than  the  per  cent  of  casein  required. 
If  so,  determine  the  ounces  of  skimmed  milk  needed  to  give  the 
additional  casein  (protein)  percentage  required  (calculation  of  x). 
Divide  the  additional  percentage  of  casein  required  by  3.20,  and 
multiply  by  the  total  number  of  ounces  in  the  mixture. 

4.  Determine  the  ounces  of  whey  needed  to  give  the  required 
whey  protein  percentage  (calculation  of  x).  Multiply  the  per  cent 
of  whey  protein  required  by  the  total  number  of  ounces  in  the 
mixture. 

5.  Determine  the  percentage  of  sugar  given  by  the  cream,  milk, 
and  whey  (calculation  of  m).  Divide  the  ounces  of  cream  -f  milk 
-f  whey  by  the  total  number  of  ounces  in  the  mixture  and  multiply 
by  4.50.  Subtract  this  from  the  percentage  of  lactose  required  to 
find  the  additional  sugar  percentage  needed, 

6.  Determine  the  ounces  of  milk  sugar  required  to  give  the  ad- 


Home  Modification  313 

ditional  sugar  percentage  required  (calculation  of  x).  Divide  the 
additional  sugar  percentage  required  by  loo  and  multiply  by  the 
total  number  of  ounces  in  the  mixture. 

7.  Reduce  the  sugar  from  ounces  to  rounded  tablespoons  by  multi- 
plying by  2. 

The  following  example  illustrates  the  calculation  of  a  split  protein 
formula : 

We  wish  to  give 

Fat  2 .  50  Lactose  6  Whe}^  protein  .  75  Casein  .  50 

8  feedings  of  4-1/2  ounces. 

In  this  case,  I  should  assume  the  total  mixture  to  be  40,  instead 

of  36,  in  order  to  avoid  fractions. 

1.    X  40  =  6i  ounces  gravity  cream. 

16 

6-25 

2.  ■ — —  X  3.20=  .50%  minimum  casein  obtainable. 

40 

In  this  case,  the  minimum  casein  obtainable  is  just  what  is  required. 
Therefore  the  third  step  is  omitted. 

4.  .  75  X  40  =  30  ounces  whey. 

36.25  36  9  9  9  81 

5.     X  4 .  50  = X = X = =  4  per  cent  of  sugar 

40  40  2  10  2  20 

added  by  the  cream  and  whey.    6  —  4  =  2%  additional  sugar  reciuired. 

2 

6. X  40=  .8  ounces. 

100 

7.     .8X2^1.6  tablespoons,  called  i\  tablespoons. 

The  mother  or  nurse  would  consequently  be  told  to  mix  as  follows: 

Cream.  6|  ounces 

Whe}',  30    ounces 

Boiled  water,    35  ounces 
Milk  sugar,       i^  tablespoons 

Calculation  of  Other  Carbohydrates  than  Lactose. — ISIost 
of  the  other  carbohydrates  are  obtainable  in  dry  form.  The  carbo- 
hydrate most  commonly  used  is  maltose,  or  a  combination  of  dextrin 
and  maltose.  There  are  a  number  of  preparations  of  "dextri-mal- 
tose"  on  the  market  which  are  excellent,  and  are,  I  believe,  the 
best  form  in  which  to  use  maltose  as  the  extra  sugar  in  cow's  milk 
modification.  These  dry  sugars  are  simply  used  as  substitutes  for 
the  lactose  added  to  ordinary  modifications.  In  using  maltose,  the 
physician  does  not  usually  think  of  a  definite  percentage  of  maltose 
which  he  wishes  to  give,  but  rather  of  the  total  sugar,  the  extra  sugar 


314  Feeding 

to  be  maltose.  The  relative  percentages  of  lactose  and  maltose  in 
this  total  carbohydrate  are  brought  out  during  the  calculation.  If 
we  wish  to  give  6  per  cent  carbohydrate,  extra  sugar  maltose,  when 
we  determine  the  per  cent  of  sugar  added  by  the  milk  and  cream  in 
the  mixture,  this  represents  the  per  cent  of  lactose,  while  the  addi- 
tional carbohydrate  percentage  required  represents  the  per  cent  of 
maltose  in  the  mixture. 

Some  of  the  carbohydrates  used  in  milk  modifications  are  sold  in 
liquid  form.  Examples  of  these  are  the  various  malt  extracts.  When 
these  are  used,  it  is  necessary  to  know  the  percentage  of  maltose  in 
the  preparation  employed.  This  figure  is  substituted  for  the  figure 
loo,  in  calculating  the  extra  sugar  required,  and  the  result  is  left 
in  fluid  ounces,  forming  a  part  of  the  total  mixture. 

Lactic  Acid  Milk  in  Home  Modification. — The  making  of 
lactic  acid  milk  for  therapeutic  use  against  intestinal  putrefaction 
will  be  described  elsewhere.  In  making  lactic  acid  milk  as  a  method 
of  modifying  cow's  milk  for  the  purpose  of  infant  feeding,  any  prepa- 
ration of  the  lactic  acid  bacillus,  such  as  lactone  tablets,  lacto- 
bacilline,  or  a  bouillon  culture  of  the  lactic  acid  bacillus  may  be 
used.  When  the  last  is  employed,  a  little  of  each  day's  milk,  one  or 
two  teaspoons,  may  be  added  to  ferment  the  milk  for  the  next  day. 

The  ferment  is  added  to  fat-free  milk,  which  should  previously 
have  been  steriHzed.  If  fat-containing  mixtures  are  fermented,  the 
fat  globules  may  fuse  together  in  the  form  of  butter,  which  may 
cause  indigestion.  After  adding  the  ferment,  the  milk  is.  allowed 
to  stand  in  a  warm  place,  the  exact  temperature  not  being  essential. 
A  little  experiment  will  show  how  long  standing  in  a  given  place 
will  suffice  to  cause  souring  of  the  milk  with  fine  precipitation  of 
the  casein,  without  separation  of  the  curd  from  the  whey.  When 
this  point  is  reached,  the  milk  is  bottled  and  put  on  ice.  If  it  cannot 
be  continuously  kept  on  ice  till  used,  it  should  be  heated  to  155°  F., 
in  order  to  kill  the  ferment. 

Lactic  acid  milk  thus  obtained  is  considered  to  have  a  formula  of 

Fat  o  Lactose  below  4 .  50  Protein  3 .  50 

The  carbohydrate  is  very  variable,  depending  on  how  far  the  fer- 
mentation has  gone.  This  food  may  be  diluted  in  various  ways  to 
meet  digestive  idiosyncrasy.  If  it  be  desired  to  give  fat,  it  is  usu- 
ally better  to  use  alternate  feedings  of  the  lactic  acid  milk  and  some 
fat-containing  formula,  although  often  a  lactic  acid  milk  containing 
a  little  cream  may  be  given  with  safety. 

Precipitated  Casein  in  Home  Modification. — This  is  obtained 
as  follows:  To  one  quart  of  skimmed  milk  add  half  an  ounce  of 
essence  of  pepsin  or  liquid  rennet,  or  two  junket  tablets.     Heat  to 


Home  Modification  315 

about  body  temperature  (ioo°  F.),  and  let  stand  until  the  casein 
has  coagulated.  Strain  off  the  whey  through  mushn.  The  curd  is 
now  rubbed  through  a  fine  wire  sieve.  During  the  process  small 
quantities  of  water  are  added  to  the  casein  in  the  sieve.  When  all 
the  casein  has  gone  through,  enough  more  water  is  added  to  bring 
the  quantity  of  the  casein  suspension  up  to  lo  ounces.  This  forms 
the  stock  precipitated  casein  solution. 

The  calculation  is  made  as  follows: — It  has  been  found  that  the 
quantity  of  casein  obtained  in  this  way  from  a  quart  is  2.60  per 
cent  of  the  quart.  Ten  ounces  is  very  little  less  than  one-third  of 
a  quart,  and  therefore  the  percentage  of  casein  in  the  lo-ounce  stock 
solution  is  represented  by  2.60  X  3  or  7.8  per  cent,  which  for  pur- 
poses of  calculation  is  considered  to  be  8  per  cent.  If  the  stock 
solution  contains  8  per  cent  of  precipitated  casein,  the  calculation 
for  obtaining  any  desired  percentage  of  precipitated  casein  in  any 
mixture  is  as  follows: — 

Divide  the  percentage  of  precipitated  casein  required  by  8,  and 
multiply  by  the  total  number  of  ounces  in  the  mixture.  This  gives 
the  number  of  ounces  of  the  stock  solution  to  be  used. 

Cooking  Milk  Mixtures. — This  procedure  requires  no  specific 
directions  in  home  modification.  The  food  is  simply  brought  to  a 
boil.     It  is  best  to  use  a  double  boiler. 

Homogenized  Milk. — This  very  recent  method  of  modifying  milk 
is  not  available  at  present  in  home  modification.  It  is  necessary 
to  resort  to  a  hospital  or  laboratory  possessing  a  homogenizer. 

Malt  Soup. — The  proportions  are  one  ounce  (by  weight)  of  wheat 
flour  to  ten  ounces  of  milk.  The  flour  is  rubbed  smooth  with  cold 
milk,  and  the  milk  and  flour  are  cooked  for  twenty  minutes,  and 
then  allowed  to  cool.  In  another  vessel  three  ounces  of  one  of  the 
thick  malt  extracts  are  dissolved,  with  15  grains  of  potassium  car- 
bonate, in  20  ounces  of  lukewarm  water.  This  is  added  to  the  milk 
and  flour,  and  the  mixture  is  kept  warm  for  a  few  minutes,  and  then 
boiled  for  five  minutes.     After  cooling  it  is  ready  for  use. 

This  mixture  has  an  approximate  percentage  formula  of 

Fat  1 .  30  Lactose  i .  50  Maltose  7 .  50  Protein  i .  00 

There  is  also  an  amount  of  starch  which  is  very  variable,  as  some 
of  the  starch  is  dextrinized  by  the  malt  extract  during  heating. 

The  essential  features  of  malt  soup  being  the  cooking  of  the  flour 
with  the  milk  and  the  warming  with  malt  extract,  any  milk  modifi- 
cation of  known  composition  may  be  treated  in  this  way. 

Albumin  Milk;  Protein  Milk;  Eiweiss  Milch. — Precipitated 
casein  is  obtained  by  the  method  described  under  that  heading, 
The  amount  of  water  added  is  up  to  one  pint  instead  of  10  ounces. 


316  Feeding 

Lactic  acid  milk  is  obtained  by  the  method  described  under  that 
heading,  but  from  whole  milk  instead  of  skimmed  milk,  and  one 
pint  is  mixed  with  the  casein  suspension. 

Albumin  milk  thus  made  has  a  constant  formula,  which  can  only 
be  altered  by  dilution,  or  the  addition  of  sugar.  .  Any  combination 
of  percentages,  however,  can  be  obtained  by  combining  the  8  per 
cent  precipitated  casein  solution  with  lactic  acid  milk  in  various 
proportions. 

LABORATORY  FEEDING  AND  HOME  MODIFICATION; 
RELATIVE    ADVANTAGES    AND    DISADVANTAGES.— In    a 

discussion  of  the  factors  which  guide  the  physician  in  choosing  whether 
the  infant's  food  shall  be  prepared  at  a  milk  laboratory  or  at  home, 
it  is  necessary  to  state  at  the  outset,  that  as  far  as  practical  results 
are  concerned,  there  has  never  appeared  to  be  am^  marked  superiority 
on  either  side.  It  appears  to  be  an  undoubted  fact  in  the  experi- 
ences of  most  physicians  who  have  had  a  large  experience  wdth  both 
methods,  that  most  infants  can  be  fed  with  food  prepared  at  home 
just  as  successfully  as  with  food  prepared  at  a  milk  laboratory.  This 
fact  appHes  to  the  majority  of  even  the  most  dif&cult  cases,  pro- 
vided that  the  home  modification  be  properly  carried  out.  The 
fact  that  the  laboratory  employs  centrifugalized  cream  instead  of 
gravity  cream'  has  been  urged  as  an  objection  to  laboratory  feeding, 
on  the  ground  that  separated  cream  is  less  digestible.  No  basis  has 
been  found  for  this  belief,  and  it  is  quite  certain  that  the  obtaining 
of  cream  by  centrifugalization  in  no  way  impairs  its  digestibihty. 

Accuracy  cannot  be  realized  with  home  modification  as  with  the 
laboratory.  In  a  food  prepared  at  the  laboratory  the  physician  can 
have  the  same  assurance  that  the  composition  of  the  food  is  exactly 
what  he  ordered,  as  he  has  in  the  case  of  his  drug  prescription  filled 
at  a  reliable  pharmacy.  That  this  superiority  in  the  exactness  of 
the  percentage  formulae  has  not  given  evidence  of  superior  clinical 
results,  only  demonstrates  that  such  absolute  accuracy,  while  desir- 
able, is  not  essential  for  practical  purposes.  Successful  clinical 
results  are  due,  not  to  exactness  of  the  composition  of  the  food  given, 
but  to  the  physician's  knowledge  of  the  resources  at  his  command  in 
artificial  feeding  and  of  the  scientific  principles  on  which  these  re- 
sources are  based,  and  to  his  skill  in  the  diagnosis  of  the  conditions 
he  has  to  treat,  and  in  the  choice  among  the  methods  at  his  disposal. 

Accuracy  is  essential  for  purposes  of  research.  If  the  physician 
is  interested  not  only  in  obtaining  good  practical  results,  but  also 
in  adding  to  his  knowledge  of  the  relation  of  clinical  manifestations 
to  various  quantities  of  the  food  elements,  or  if  he  is  treating  cases 
experimentally  with  the  idea  of  pubhshing  his  findings,  results  based 
on  home  modification  cannot  be  used,  because  of  inaccuracy. 


Calculation  of  Calories  317 

The  principal  practical  advantage  in  laboratory  modification  is  its 
convenience.  It  spares  the  physician  all  the  trouble  of  the  mathe- 
matical calculations  involved  in  home  modification,  and  spares  the 
mother  or  nurse  the  trouble  of  obtaining  and  mixing  the  ingredients. 
In  any  case  in  which  there  is  any  doubt  as  to  the  willingness  or 
ability  of  nurse  or  mother  to  modify  the  milk  exactly  as  directed, 
under  conditions  of  perfect  cleanliness,  laboratory  modification,  if 
available,  should  be  preferred.  Furthermore,  laboratory  modifica- 
tion as  carried  out  by  the  best  milk  laboratories  in  this  country, 
insures  that  the  cow's  milk  used  is  of  the  best,  although  in  many 
places  an  equally  good  milk  may  be  secured  for  home  modification. 
In  short,  laboratory  feeding  secures  accuracy,  convenience,  and 
cleanliness. 

The  practical  disadvantage  of  laboratory  modification  is  the  cost 
of  the  product;  this  has  to  be  considered  in  many  families.  Som- 
times  the  laboratory  is  available,  but  is  situated  at  such  a  distance, 
that  the  cost  is  increased  by  the  expense  of  transportation. 

The  wishes  of  the  mother,  even  if  founded  on  prejudice,  must 
sometimes  be  considered  in  making  a  choice.  One  often  encounters 
the  idea  that  a  skillful  mother  or  nurse,  whose  "heart  is  in  her  work," 
who  is  in  daily  contact  with  "dear  little  Tommy,"  and  who  is  famil- 
iar with  his  "cunning  ways,"  is  less  likely  to  make  mistakes  than  a 
mere  paid  laboratory  clerk  who  has  never  even  seen  the  baby.  Such 
an  idea,  even  if  false,  calls  for  sympathy,  and  if  the  available  milk 
supply  is  good,  if  the  mother  or  nurse  is  skillful,  and  if  special  accu- 
racy is  not  desired,  home  modification  may  be  chosen.  In  such  a 
case  when  greater  accuracy  is  desired,  the  physician  can  order  stand- 
ardized cream  and  fat-free  milk  from  the  laboratory,  and  let  the 
interested  nurse  or  mother  do  the  mixing.  The  physician  should 
not  allow  himself  to  be  driven  to  home  modification  by  any  such 
false  prejudice  as  that  the  laboratory  makes  mistakes,  or  that  it 
dispenses  some  particular  kind  of  food,  but  should  explain  that  the 
purpose  of  the  laboratory  is  the  same  as  that  of  the  pharmacy,  to 
carry  out  the  physician's  prescriptions  with  accuracy,  cleanliness, 
and  convenience.  Of  course,  in  very  many  places,  the  need  of  a 
choice  does  not  exist;  no  milk  laboratory  is  available,  and  home 
modification  must  be  employed.  When  there  is  a  choice,  the  physi- 
cian must  take  into  consideration  all  the  circumstances.  He  must 
consider  the  milk  supply  available  for  home  modification,  the  finan- 
cial and  geographical  situation  of  the  family,  the  internal  conditions 
of  the  household,  the  complexity  of  the  feeding  method  to  be  em- 
ployed, and  whether  the  particular  case  calls  for  especial  accuracy. 

CALCULATION  OF  THE  CALORIES.— The  estimation  of  the 
daily  calories  per  kilogram  of  body  weight,  for  the  purpose  of  com- 


318  Feeding 

parison  with  the  so-called  minimum  caloric  requirement,  is  often 
useful  in  infant  feeding,  thou^  its  utihty  is  rather  as  a  check  than  as 
a  guide.  This  calculation  is  made  from  the  known  composition  of 
the  food  expressed  in  percentages.  The  "caloric  coefficients"  are 
9.3  for  fat,  and  4.1  for  carbohydrate  and  protein.  This  means  that 
one  gramme  of  fat  has  a  value  of  9.3  calories,  and  one  gramme  of 
carbohydrate  or  protein  has  a  value  of  4.1  calories.  The  calcula- 
tion is  made  as  follows: 

1.  Multiply  9.3  by  the  figure  representing  the  percentage  of  fat 
and  divide  by  100. 

2.  Multiply  4.1  by  the  sum  of  the  percentages  of  carbohydrate  and 
protein,  and  divide  by  ico.  This  gives  the  -caloric  value  of  the 
carbohydrate  and  protein  in  one  gramme  of  food. 

3.  Add  these  two  results  together.  This  gives  the  caloric  value 
of  one  gramme  of  food. 

4.  Multiply  the  food  taken  in  24  hours,  if  expressed  in  ounces, 
by  30,  to  reduce  to  cubic  centimeters.  Multiply  this  by  the  caloric 
value  of  one  gramme  of  food.  This  gives  the  daily  number  of  calories 
ingested. 

5.  To  reduce  the  weight  of  the  baby  from  pounds  to  kilograms, 
multiply  the  weight  in  ounces  by  30,  and  divide  by  1000. 

6.  Divide  the  daily  calories  taken,  by  the  weight  of  the  baby  in 
kilograms.     This  gives  the  daily  calories  per  kilogram  of  body  weight. 

As  an  example  of  this  calculation,  let  us  suppose  that  a  baby 
weighing  9  lbs.  8  oz.  is  taking  daily  32  ounces  of  a  food,  of  which  the 
composition  is  represented  by  the  formula  fat  2,  lactose  6,  protein  2. 
The  steps  of  the  calculation  are: — 

9.3X2-4-  100=  .186  Ca.  from  fat  in  one  gramme  of  food. 
4.1  X  8  -f-  100=  .328  Ca.  from  carbohydrate  and  protein  in  one 
gramme  of  food. 

3.  .186 -h  .328  =  .514  Ca.  in  one  gramme  of  food. 

4.  32  X  30  =  960  grammes  of  food  in  24  hours. 
960  X  -  514  =  493 .44  calories  ingested  daily. 
9  lbs.  8  oz.  =  152,  weight  of  baby  in  ounces. 
152  X  30  -^  1000  =  4.56,  weight  of  baby  in  kilograms. 
493.44  -H  4.56  =  108,  daily  calories  per  kilogram  of  body  weight. 

CALCULATION  OF  PERCENTAGE  COMPOSITION  IN  A 
FOOD  OF  KNOWN  INGREDIENTS.— In  order  to  treat  intel- 
ligently a  case  of  difficult  feeding,  it  is  necessary  to  know  all  the 
foods  previously  used,  and  how  well  the  baby  thrived,  and  what 
symptoms  it  manifested  with  each  food.  In  order  to  draw  from  such 
a  history  conclusions  which  shall  serve  as  a  guide  in  choosing  the 
method  of  feeding  to  be  employed,  it  is  necessary  to  know  the  com- 
position of  each  previous  food  as  expressed  in  percentage.  In  the 
history  of  the  case,  the  previous  foods  are  often  described,  not  as 
percentage  formulae,  but  as  mixtures  of  ingredients.     These  mix- 


Calculation  of  Percentage  Composition 


319 


tures  have  to  be  reduced  to  a  formula  representing  the  composition 
of  the  food  in  percentages  of  the  principal  food  elements. 

To  reduce  mixtures  to  their  percentage  formulae  requires  that  we 
shall  know  the  composition  of  each  ingredient  used.  Many  of  the 
ingredients  met  with  are  creams  of  different  fat  percentages,  or  whole 
milk,  or  whey.  We  can  only  judge  the  fat  percentage  of  a  cream  or 
milk  used,  by  ascertaining  the  procedure  employed  by  the  mother 
or  nurse  in  obtaining  these  ingredients.  The  percentage  of  fat  in 
a  cream  or  "top  milk"  varies  with  the  number  of  ounces  removed 
from  the  top  of  the  jar. 

The  following  table  shows  the  average  composition  as  expressed 
in  percentages,  of  top  milks  obtained  in  various  ways,  and  of  the 
other  ingredients  most  commonly  met  with  in  the  history  of  cases 
of  artificial  feeding. 

Table  32 

Percentage  Composition  of  Various  Ingredients  Used  in  Preparing  Food  for  Infants. 

Top  Milk 

NUilBER  OF  OUNCES 

TAKEN  EROM  QUART  FAT 

4  (or  less) 20 .  00 

6  (or  all  the  cream) 16 .  00 

8 1 2 .  00 

II 10.00 

16  (upper  half) 7 .  00 


CARBOHYDRATE 

PROTEIN 

4.00 

2.80 

4.20 

305 

4-36 

3.18 

4-45 

3-27 

4-55 

3-41 

Other  Milks  and  Creams 


FAT 

Whole  milk 4 .  00 

Skimmed  milk i .  00 

Separated  cream 32  .  00 

Separated  fat-free  milk 0.05 

Whey o.  25 

Commercial  buttermilk 0.50 

Fat-free  lactic  acid  milk o .  00 

Whole  lactic  acid  milk 4 .  00 

Albumin  milk 2  .  00 

Malt  soup  with  whole  milk i  •  30 

Condensed  milk 9.61 


CARBOHYDRATE        PROTEIN 


4 

75 

350 

5 

00 

3-55 

3 

5 

40 
08 

2.50 
3.60 

5 
4 
4 
4 

10 
06 

06 

GO 

0.90 
3.60 
3.60 
3.60 

2 

SO 

3.00 

Q 

00 

1. 00 

54 

94 

8.01 

Other  Ingredients 


FAT 

Dry  carbohydrate o .  00 

Malt  extract o .  00 

Barley  water o .  00 


CARBOHYDRATE 

PROTEIN 

100.00 

0.00 

75- 00 

0.00 

1-50 

0.00 

At  times  some  one  of  the  widely  advertised  infant  foods  has  been 
used  in  the  previous  feeding  of  a  baby.  These  foods  are  mainly  carbo- 
hydrate, though  some  of  them  have  evaporated  or  condensed  milk  as  a 
basis,  which  gives  them  a  considerable  fat  and  protein  content.  The 
composition  of  condensed  milk  appears  in  the  table  of  ingredients. 


320 


Feeding 


Of  the  54.94  per  cent  of  carbohydrate  contained  in  condensed  milk, 
42.91  per  cent  is  cane  sugar,  and  12.03  per  cent  is  milk  sugar.  Most 
of  the  other  infant  foods  are  in  dry  form.     Their  composition  is 

shown  in  the  following  table,  taken  from  Holt. 


Table  33 
The  Composition  of  the  Infant-foods.     {Holt) 


XESTLE  3 
FOOD 

Per 
cent 

Fat 5.50 

Protein 14 -34 

Cane  sugar 25 .  00 

Dextrose 

Lactose  (milk  sugar) .  .     6.57 

Maltose \         . 

Dextrins J27.30 

Total  soluble  carbo- 
hydrates    58.93 

Insoluble  carbohy- 
drates (starch) 15-39 

Inorganic  salts 2 .  03 

Moisture ^ .  81 


MEL- 

LEsr's 

FOOD 

Per 

cent 

0.24 

11-50 


60.80 
19.20 

So .  00 


3-59 
4-73 


C-AiLN- 

ESKAY's    ILALTED     RIDGe'S  IMPERIAL    RICk'S 
FOOD       GR.AXUM 

Per  Per 

cent         cent 


FOOD 

Per 

cent 
,16 
.82 


inLK 
Per 
cent 
8.78 
16.35 


49-15 
18.80 

67-95 


3-86 
3.06 


1 .  II 
II. 81 

0-52 

1.28 

1.80 

76.21 
0.49 
8. 58 


1 .04 

14.00 

0.42 

i"38 

1.80 

73-54 
0.39 
9-23 


FOOD 

Per 
cent 

7-45 


10 


The  calculation  of  the  percentages  in  the  mixture  given  to  the 
baby  from  the  known  composition  of  the  ingredients,  is  made  from 
the  same  proportion  as  was  used  in  home  modification — 


X  :  a=  m  :  n 


In  this  case,  the  unknown  quantity  is  ;;z,  its  value  being  expressed  by 


X  n 


Divide  the  number  of  ounces  of  the  ingredient  used  by  the  number 
of  ounces  in  the  mixture,  and  multiply  by  the  percentage  of  any 
element  in  the  ingredient.  This  is  repeated  for  each  food  element, 
and  for  each  ingredient. 

For  example,   a  mother  is  preparing  her  food  as   follows: — She 
takes  the  upper  11  ounces  from  a  quart  of  milk,  and  mixes  as  follows: 

Cream.  8  ounces 

Skimmed  milk,  10  ounces 
Lime  water,  2  ounces 

Barley  water,      20  ounces 
Dextri-maltose,    4  tablespoons 

The  total  mixture  is  40  ounces,  and,  as  will  be  seen  by  reference  to 
table  32,  the  cream  is  10  per  cent  fat. 


Practical  Feeding  321 

8 

X  lo      =  2%  fat  from  the  cream. 

40 

10 

X  I        =  .  25  fat  from  the  skimmed  milk. 

40 

8 

X  3.  27  ^  .65  protein  from  the  cream. 

40 

10 

X  3  •  55  =  .88  protein  from  the  skimmed  milko 

40 

8 

X  4.45  =  .89  lactose  from  the  cream. 

40 

10 

X  5        =  1 .  00  lactose  from  the  skimmed  milk. 

40 

4  tablespoons  dextri-maltose  -^  2  =  2  ounces. 

2 
X  100   =5%  maltose. 

40 

20 
X  1 .  50  =  ■  75%  starch. 

40 

2 

X  100   ^  .  11%  of  the  milk  and  cream  for  lime  water. 

18 

Therefore  this  food  represents  in  percentages — fat  2.25,  lactose 
1.89,  maltose  5.00,  protein  1.53,  starch  .75,  lime  water  11  per  cent 
of  the  milk  and  cream. 

PRACTICAL  MANAGEMENT  OF  ARTIFICIAL  FEEDING 

GENERAL  PRINCIPLES 

There  are  certain  general  principles  which  govern  the  manage- 
ment of  all  cases  of  artificial  feeding. 

Ends  to  be  Attained. — The  first  object  in  artificial  feeding, 
which  should  be  kept  in  view  as  the  principal  end  to  be  attained,  is 
to  secure  the  normal  development  of  the  infant.  The  most  useful  meas- 
ure of  development  is  the  progressive  gain  in  weight  which  is  seen  in 
normal  infants,  and  the  absence  of  which  is  the  most  frequent,  early 
and  important  sign  seen  in  any  disturbance.  The  second  object 
desired  in  artificial  feeding  is  to  keep  the  infant  free  from  all  symp- 
toms and  signs  of  disturbed  digestion.  This  second  object  usually 
goes  with  the  first,  as  babies  who  show  signs  of  disturbed  digestion 
do  not  gain  weight  normally.  Sometimes,  however,  a  baby  may 
fail  to  thrive  without  showing  recognizable  symptoms  of  disturbed 
digestion;  while  conversely,  some  babies  will  continue  to  gain  nor- 
21 


322  Feeding 

mally  in  weight,  even  when  digestive  symptoms  are  present.     The 
third  object  is  to  develop  the  digestive  powers  of  the  infant. 

Conditions  of  the  PnOBLEM.^The  difficulties  encountered  in 
attaining  these  objects  are  due  mainly  to  the  variation  in  the  diges- 
tive powers  and  nutritive  requirements  of  different  babies.  To  meet 
these  difficulties  we  are  provided  with  the  various  methods  of  modi- 
fying cow's  milk  which  constitute  our  stock  of  weapons.  The  prob- 
lem is  to  choose  our  methods  so  as  to  attain  the  desired  object.  Suc- 
cess depends  on  our  knowledge  of  the  tools  to  be  employed,  of  the 
principles  underlying  their  use,  and  the  skill  with  which  we  choose 
among  them. 

Feeding  a  baby  is  always  an  experiment.  The  artificial  feeding 
of  infants  is  not,  and  never  will  be,  an  exact  science.  We  know  at 
the  start,  only  that  the  baby  must  be  fed  on  some  combination  of 
fats,  carbohydrates  and  protein.  We  know  that  this  food  must  be 
given  in  proper  amounts,  and  at  proper  intervals.  We  know  that 
the  milk  supply  used  must  be  as  clean  as  possible.  We  must  decide 
whether  or  not  the  milk  is  to  be  pasteurized  or  sterilized,  and  whether 
we  shall  employ  a  milk-laboratory  or  home  modification. 

The  principles  which  guide  us  in  the  decision  as  to  these  two  last 
points  have  already  been  described.  The  principles  underlying  the 
decision  as  to  the  quantity  of  food  to  be  given  each  twenty-four 
hours,  and  as  to  the  feeding  intervals  are  comparatively  simple. 
The  principal  problem  is  to  choose  the  composition  of  the  food. 

GENERAL  CONDUCT  OF  A  CASE  OF  ARTIFICIAL  FEED- 
ING.— The  various  steps  taken  in  carrying  on  a  case  of  artificial 
feeding  are  the  following: 

1.  A  careful  history  of  the  case  is  obtained.  Such  a  history  should 
include  the  entire  past  feeding  of  the  child;  if  bottle  feeding  has  been 
used,  the  composition  of  each  food  should  be  translated  into  per- 
centages. The  regularity,  intervals,  and  amounts  of  feeding  should 
be  inquired  into.  The  reaction  of  the  child  to  each  food  used  should 
be  ascertained.  In  particular,  such  questions  as  to  whether  or  not 
the  child  gained  in  weight,  whether  or  not  it  seemed  satisfied  or 
hungry,  whether  or  not  the  bowels  moved  properly,  should  be  recorded 
in  detail.  All  the  possible  symptoms  of  indigestion,  such  as  vomit- 
ing, regurgitation,  sour  eructation,  coUc,  excoriated  buttocks,  should 
be  inquired  into.  The  daily  number,  and  character  of  the  bowel 
movements  should  be  ascertained.  From  such  a  history  may  often 
be  deduced  important  facts  as  to  the  digestive  idiosyncrasy  of  the 
baby. 

2.  The  initial  food,  on  which  the  baby  is  to  be  started,  is  now 
chosen.  The  basis  of  choice  is  any  deductions  which  have  been 
made  from  the  past  history,  together  with  the  knowledge  and  experi- 


Feeding  of  Normal  Infants  323 

ence  of  the  physician  in  artificial  feeding.  If  the  baby  has  been 
previously  breast-fed,  or  if  the  past  history  is  not  of  such  a  char- 
acter as  to  permit  any  deductions  influencing  the  choice,  the  only 
guide  is  the  age,  weight,  and  apparent  development  of  the  baby. 

3.  The  initial  food  is  always  a  sort  of  trial  formula.  The  greater 
the  knowledge  of  the  physician,  the  more  apt  is  the  first  food  chosen 
to  give  a  good  result.  It  is,  however,  mainly  on  the  results  observed 
with  this  initial  food,  that  the  further  conduct  of  the  case  is  based. 

4.  The  composition  of  the  food  is  changed  from  time  to  time. 
The  changes  are  based  on  the  reaction  of  the  baby  to  the  trial  formula 
first  chosen.  If  the  baby  shows  symptoms  of  indigestion,  and  failure 
to  gain  in  weight,  changes  are  made  in  the  composition  of  the  food, 
with  the  purpose,  first,  of  obtaining  a  gain  in  weight,  and  second, 
relieving  symptoms.  If  the  baby  gains  weight,  but  shows  symp- 
toms of  indigestion,  the  changes  in  the  food  are  made  in  the  eft'ort 
to  relieve  the  symptoms.  If  the  baby  shows  no  symptoms  but  fails 
to  gain,  the  object  of  changing  the  food  is  to  make  the  baby  gain. 

5.  In  artificial  feeding,  even  when  a  baby  is  free  from  symptoms 
of  indigestion,  and  is  gaining  weight,  we  should  not  rest  satisfied 
indefinitely,  but  should  still  change  the  composition  of  the  food 
from  time  to  time,  with  the  idea  of  increasing  the  burden  laid  upon 
the  infant's  digestive  powers,  without  overburdening  them.  This  is 
dotie,  because  one  of  the  principal  objects  to  be  kept  in  view  in 
artificial  feeding,  is  the  strengthening  of  the  infant's  digestive  power. 
Any  function  deteriorates  when  not  exercised.  In  general,  it  is 
always  best  within  certain  limits  to  work  a  baby  up  to  taking  a  food 
of  as  strong  a  composition  as  it  can  digest. 

6.  The  various  changes  made  in  the  composition  of  the  food  should 
be  carried  out  in  such  a  way  as  to  enable  the  physician  to  learn  as 
much  as  possible  about  the  digestive  peculiarities  of  the  baby.  It 
is  often  best  to  change  the  quantity  of  just  one  food  element  at  a 
time,  in  order  to  draw  conclusions  as  to  the  baby's  power  of  digest- 
ing each  one. 

THE  FEEDING  OF  NORMAL  INFANTS 

There  is  no  such  thing  as  a  normal  infant  with  digestive  powers 
and  nutritive  requirements  which  conform  to  any  standard.  What 
is  meant  by  a  normal  infant,  is  a  baby  who  has  previously  had 
no  symptoms  of  indigestion.  Babies  who  have  been  previously 
breast-fed,  without  signs  of  indigestion,  or  babies  in  whom  bottle 
feeding  has  failed  to  reveal  any  weakness  of  digestive  power,  or 
babies  who  are  artificially  fed  from  birth,  are  considered  normal, 
when  the  first  choice  of  artificial  food  is  made.  They  continue  to 
be  considered  normal  when  the  first  artificial  food  chosen  causes  no 
disturbance.  In  such  a  case,  after  having  decided  as  to  home  or 
laboratory  modification,  and  as  to  pasteurization,  we  must  decide 


324  Feeding 

three  points;  first,  the  quantity  of  the  food;  second,  the  intervals  of 
feeding;  and  third,  the  composition  of  the  food. 

THE  QUANTITY  OF  THE  FOOD  TO  BE  GIVEN.— The  most 
important  thing  is  the  quantity  to  be  given  in  the  twenty-four  hours. 
The  guide  in  beginning  artificial  feeding  is  the  age  and  development 
of  the  baby;  the  latter  is  measured  chiefly  by  the  infant's  weight. 
Table  34  shows  the  twenty-four  hour  quantities  in  ounces  for  babies 
of  average  weight  at  different  ages.  The  figures  are  based  on  the 
quantities  taken  by  healthy,  breast-fed  infants.  Big  babies  require 
more  food  than  small  babies. 

The  guide  as  to  making  changes  in  the  quantity  after  artificial 
feeding  has  been  begun,  is  the  behavior  of  the  baby.  When  a  baby 
is  not  satisfied  with  the  quantity  of  food  given,  he  shows  symp- 
toms of  hunger.  Such  symptoms  may  be  relieved  either  by  in- 
creasing the  quantity  of  the  food,  or  by  strengthening  its  percentage 
composition.  Either  increase  may  cause  indigestion.  If  the  baby 
seems  satisfied  immediately  after  feeding,  but  begins  to  cry  and  fuss 
too  long  before  the  next  feeding  is  due,  the  deficiency  is  more  apt 
to  be  in  the  quality  of  the  food,  while  if  the  hunger  symptoms  are 
seen  as  soon  as  he  has  finished  his  bottle,  increase  in  quantity  is  more 
apt  to  relieve  them.  This  guide  is,  however,  by  no  means  positive. 
Generally  a  baby  should  be  given  from  the  start  the  full  quantity 
for  his  weight  and  age.  Then,  as  a  normal  baby  should  preferably 
have  as  strong  a  food  as  he  can  digest,  the  quality  should  be  in- 
creased first,  until  he  is  either  satisfied,  or  begins  to  show  signs  of 
indigestion.  Only  when  the  limit  in  increase  in  quality  is  reached 
should  the  quantity  be  raised. 

The  amount  of  food  in  ounces  to  be  given  at  a  feeding  is  the  next 
thing  to  be  decided.  It  would  seem  at  the  first  glance  that  the 
most  scientific  basis  for  determining  the  quantity  to  be  given  at  a 
feeding  is  the  gastric  capacity  of  infants  at  various  ages.  Two 
methods  have  been  employed  in  estimating  gastric  capacity.  The 
first  is  by  post-mortem  measurements  of  actual  capacity;  the  second 
is  by  measuring  the  quantity  of  food  taken  at  a  feeding  by  a  healthy 
breast-fed  infant.  Both  have  proved  rather  unsatisfactory  as  prac- 
tical guides.  The  technique  of  post-mortem  measurements  is  com- 
plicated, and  the  results  vary,  not  only  with  individual  babies,  but 
according  to  the  technique  employed.  Moreover,  it  has  been  clearly 
shown  that  the  quantity  of  fluid  a  baby  takes  in  nursing  is  not  lim- 
ited by  gastric  capacity,  as  a  portion  of  the  feeding  is  passed  into  the 
duodenum  before  the  nursing  is  completed.  It  would  seem  that  the 
capacity  as  estimated  by  the  second  method,  measuring  the  quantity 
taken  from  the  breast,  should  be  a  more  logical  basis  for  artificial 
feeding.     Here  again,   however,   individual  variation  plays   a  very 


Feeding  of  Normal  Infants 


325 


important  part.  Also,  the  standard  for  breast-fed  babies  is  not 
applicable  to  the  artificially  fed,  who  are  taking  a  food  less  ideally 
suited  to  their  needs.  In  general,  in  determining  the  quantities  to 
be  given  in  each  bottle  feeding,  the  figures  on  gastric  capacity  based 
on  post-mortem  measurements,  should  be  taken  as  a  minimum,  and 
those  based  on  the  quantities  taken  by  breast-fed  babies,  should  be 
taken  as  a  maximum. 

Some  rule  is  necessary  as  a  guide  in  beginning  artificial  feeding. 
The  important  factors  are  the  twenty-four  hour  quantity,  and  the 
intervals  between  feedings.  The  quantities  given  in  table  34  have 
been  based  on  all  the  various  forms  of  evidence  on  the  subject.  They 
tend  to  represent  minimum,  rather  than  maximum,  quantities. 

THE  INTERVALS  BETWEEN  FEEDINGS.— Artificial  feeding 
does  not  require  any  different  arrangement  of  the  feeding  intervals 
than  that  of  breast  feeding.  The  subject  of  the  feeding  intervals 
has  been  already  discussed.     They  are  shown  in  the  table — 

Table  34 
QuanlUies  and  Intervals  for  Healthy  Babies  of  Average  Development 

NUMBER 

OF 
FEEDINGS  QUANTITY  QUANTITY 

IN  NIGHT  AT  A  IN  INTER- 

24  HOURS  FEEDINGS    FEEDING  24  HOURS  VALS 

Premature 24-18  3  |-     f  oz.  3-18  oz.  i-i|  hours 

At  term 10  i  ^  oz.  5  oz.  2  hours 

First  week 10  i  i     oz.  10  oz.  2  hours 

I-  2  weeks 10  i  ij-  i|  oz.  12-15  oz.  2  hours 

2  weeks-i  month 10       _         i  i^-  2     oz.  15-20  oz.  2  hours 

1-  2  months 10  i  2  -2^    oz.  20-25  oz.  2  hours 

2-  3  months 8  i  3  -  4    oz.  24-32  oz.  2I  hours 

3-  4  months 8  or  7  i  or  o  4-  4^  oz.  28-36  oz.  2|  hours 

4-  5  months 7  or  6  i  or  o  4^-  5I  oz.  30-33  oz.  3  hours 

5-  6  months 6  o  5§-  6    oz.  33-36  oz.  3  hours 

6-  7  months 6  o  6  -  6|  oz.  36-40  oz.  3  hours 

7-  8  months 6  o  6 J-  7    oz.  40-42  oz.  3  hours   * 

8-  9  months 6  o  7-  8    oz.  42-48  oz.  3  hours 

9-T0  months 6  o  8  -  8|  oz.  48-52  oz.  3  hours 

10-12  months 5  o         9  -10    oz.         45-50  oz.         3  hours 

The  table  is  not  intended  for  arbitrary  or  literal  application,  but 
rather  as  a  general  guide.  For  this  reason  alternatives  in  arranging 
the  quantities  and  intervals  have  been  omitted,  in  order  to  make 
the  table  as  simple  as  possible.  In  general,  the  intervals  of  feeding, 
and  the  quantities  to  be  given  at  a  single  feeding  should  be  considered 
as  minimum  figures.  In  other  words,  the  change  from  2-1/2  to 
3-hour  intervals,  and  the  omitting  of  the  night  feeding,  may  often 
be  advantageously  made  at  ages  earlier  than  those  given  in  the 
table.  When  this  is  done,  the  amount  given  in  the  24  hours  should 
be  kept  constant,  and  the  quantity  given  at  a  single  feeding  should 
be  proportionately  increased. 


326  Feeding 

For  example,  a  baby  in  the  second  month  is  to  be  artificially  fed. 
The  table  gives  lo  feedings  of  2  or  2-1/2  oz.  each  at  2-hour  inter- 
vals, with  one  night  feeding  as  the  proper  routine.  At  any  age 
the  night  feeding  should  be  omitted  as  soon  as  possible.  If  the 
night  feeding  can  be  omitted,  the  baby  will  have  nine  feedings  of 
2-1/2  oz.  each,  which  will  give  him  22-1/2  oz.  in  24  hours,  which 
comes  within  the  limits  of  the  quantity  he  should  take  in  24  hours. 
Often  at  this  age,  2-1/2  hour  intervals  are  better.  If  the  baby  is 
fed  at  2-1/2  hour  intervals  with  a  night  feeding,  he  will  get  8  feedings, 
of  2-1/2  oz.,  and  20  ounces  in  24  hours,  and  if  he  does  not  need  a 
night  feeding,  he  will  get  7  feedings,  only  1 7-1/2  oz.  in  24  hours. 
In  such  a  case  the  quantity  given  at  a  single  feeding  should  be  raised 
to  3  oz. 

PERCENTAGE  FORMULAE  FOR  STARTING  AVERAGE 
WELL  BABIES. — In  choosing  the  food  with  which  to  start  artificial 
feeding,  three  main  principles  should  be  kept  in  mind. 

1.  The  feeding  of  normal  infants  does  not  require  any  of  the  more 
complicated  methods  of  cow's  milk  modification.  The  first  method, 
of  milk  and  cream  dilution,  with  the  addition  of  lactose,  usually 
suffices.  The  whey  modification,  however,  may  often  be  advan- 
tageously used  in  starting  newborn  or  very  young  babies. 

2.  The  general  relation  between  the  quantities  of  fat,  carbohy- 
drate, and  protein,  should  be  based  on  the  relation  found  in  human 
milk.  This  means  that  the  food  element  having  the  highest  per- 
centage in  the  formula  should  be  the  carbohydrate,  with  the  fat  next, 
and  protein  last.  The  percentage  of  fat  should  never  exceed'  4%,  and 
in  home  modification,  to  allow  for  error,  3.50%  is  a  safer  limit.  The 
carbohydrate  should  never  exceed  7%  in  well  babies,  nor  in  sick  babies 
except  under  the  most  exceptional  circumstances.  The  protein  should 
not  exceed  3-jo%. 

3.  It  is  better  to  begin  with  a  comparatively  weak  food,  which 
will  probably  be  digested  by  the  infant,  even  if  such  a  food  does 
not  meet  the  caloric  needs  of  the  infant.  It  is  easy  to  work  up  from 
a  weak  food  to  a  strong  one,  if  necessary.  When  indigestion  has 
once  been  produced,  it  is  not  so  easy  to  find  the  right  combination. 
Infants  of  the  saihe  age  show  such  variation  in  their  power  of  digest- 
ing cow's  milk,  that  if  we  want  the  food  to  produce  no  symptoms, 
it  is  better  to  begin  with  a  minimum. 

The  table  shows  the  percentage  formulae  with  which  artificial 
feeding  may  be  begun  at  different  ages. 

In  the  table  the  unmodified  protein  and  spht  protein  are  alter- 
natives. Some  very  young  babies  will  take  a  split  protein  better 
than  an  unmodified  protein.  The  probability  of  advantage  is  not 
great  enough  to  make  the  more  troublesome  preparation  of  a  split 


Feeding  of  Normal  Infants 


327 


Table  35 
Formulae  for  Starting  Artificial  Feeding 

PROTEIN   PROTEIN  IF  SPLIT 


CUNMODI- 

\VSEY 

AGE 

FAT 

LACTOSE 

FIEDj 

PROTEIN 

CASEIN 

STARCH 

First  food  (after 

birth) 

1 .00 

=;  .00 

0.50 
0.75 

0.  KO 

0.  2^ 

I  week-i  month. 

1.50 

J 

5 

50 

0 

75 

0 

25 

I-  2  months  . 

2  .00 

6 

00 

I  .00 

0 

90 

0 

25 

2-  4  months  . 

2.50 

6 

50 

I -5° 

4-  6  months  . 

3.00 

7 

00 

1-75 

6-  8  months  . 

3-50 

7 

00 

2.00 

0-7S 

8-10  months  . 

4.00 

6 

50 

2.50 

0.7s 

10-12  months  . 

4.00 

5 

50 

3.00 

1 

1.50 

T           1 

protein  formula  actually  indicated  in  these  young  babies.  In  home 
modification  the  minimum  casein  is  not  so  low  as  in  laboratory  mod- 
fication,  and  I  usually  do  not  order  the  split  protein  in  young  babies 
when  home  modification  is  to  be  employed.  In  laboratory  feeding, 
I  usually  begin  babies  under  two  months  with  the  split  protein, 
and  then  gradually  increase  the  casein  and  diminish  the  whey  pro- 
tein, until  the  composition  of  unmodified  protein  is  reached. 

In  babies  over  the  age  of  six  months,  I  usually  add  starch  to  the 
modification.  At  this  age,  babies  require  a  comparatively  high  per- 
centage of  protein,  and  they  can  usually  digest  starch.  Therefore, 
there  is  no  reason  why  the  favorable  colloidal ,  action  of  the  starch 
should  not  be  taken  advantage  of.  The  appearance  of  the  teeth 
at  about  the  age  of  six  months  is  Nature's  sign  that  the  time  is  ap- 
proaching for  some  other  food  beside  milk.  The  next  addition  to 
the  infant's  diet  is  naturally  to  be  starch. 

The  reason  that  the  percentage  of  lactose  is  diminished  in  the 
formulae  given  for  babies  in  the  last  four  months  of  the  first  year, 
is  that  at  this  age  one  is  beginning  to  work  up  the  food  of  the  baby 
from  modified  milk  to  whole  milk.  This  is  done  by  increasing  the 
protein  and  diminishing  the  carbohydrate,  and  babies  at  this  age 
are  started  on  slightly  diminished  carbohydrate  in  preparation  for 
whole  milk. 

Table  35  does  not  represent  the  strength  of  the  food  which  should 
be  taken  by  average  well  babies  at  the  different  ages,  but  only  the 
formulae  for  starting  them  with  safety.  If  these  initial  formulae  cause 
any  symptoms  of  indigestion,  such  babies  are  no  longer  considered 
normal,  and  the  future  management  of  artificial  feeding  comes  under 
the  treatment  of  disturbances  of  digestion.  If  the  initial  formula 
does  not  cause  symptoms,  we  should  not  rest  content,  even  if  the 
baby  is  gaining  in  weight,  but  should  increase  the  strength  of  the 
food.  The  limit  of  such  increase  is  the  digestive  power  of  the  infant. 
But  one  does  not  wish  to  pass  this  limit  and  produce  symptoms  of 
indigestion.  The  limit  is  unknown.  There  are,  however,  certain 
formulae  which  can  usually  be  taken  by  the  average  well  baby,  on 


A.CTOSE 

PROTEIN 

STA 

6.00 

0.75 

6.50 

1. 00 

7.00 

I -SO 

y.oo 

2.00 

7.00 

2.50 

0. 

6.00 

3.00 

I. 

328  Feeding 

which  the  baby  would  have  been  started  if  we  had  not  wished  to  be 
on  the  safe  side  in  beginning  artiiicial  feeding. 

PERCENTAGE  FORMULAE  FOR  FEEDING  AVERAGE 
WELL  BABIES. — This  table  represents  the  strength  of  the  food 
which  we  should  try  to  give  to  average  well  babies,  after  artificial 
feeding  has  been  successfully  started. 

Table  36 
Formulae  for  the  Feeding  of  Average  Well  Babies 

AGE  FAT 

I  week-i  month 2 .00 

I-  2  months 3  ■  00 

2-4  months 35° 

4-  6  months 4 .  00 

6-  8  months 4 .  00  7 .  00  2 .  50  o  •  75 

8-10  months 4 .  00 

10-12  months Whole  milk  with  cereal  jelly. 

INCREASING  THE  STRENGTH  OF  THE  FOOD.— The  indi- 
cations for  increasing  the  strength  of  the  food  are  three,  i.  If  the 
baby,  being  free  from  symptoms  of  indigestion,  is  not  gaining,  the 
strength  of  the  food  should  be  increased,  provided  that  the  micro- 
chemical  examination  of  the  stools  does  not  show  an  excessive  amount 
of  fat.  If  the  stools  show  excessive  fat  elimination,  the  baby  cannot 
be  considered  an  average  normal  infant,  and  the  management  of 
such  a  case  is  guided  by  the  principles  described  under  disturbances 
of  digestion.  2.  If  the  baby  is  gaining,  but  if  the  strength  of  the 
food  is  below  that  usually  taken  by  an  average  baby  of  that  age, 
the  strength  of  the  food  should  be  increased.  3.  If  the  baby,  already 
taking  a  food  of  as  great  strength  as  is  usually  taken  by  a  baby  of 
that  age,  shows  signs  of  hunger,  but  no  signs  of  indigestion,  increase 
is  indicated. 

In  well  babies,  when  increase  in  the  strength  of  the  milk  modi- 
fication is  indicated,  it  should  be  gradual.  It  is  not  necessary,  how- 
ever, to  increase  only  one  of  the  food  elements  at  a  time.  A  slight 
increase,  such  as  for  example,  an  increase  of  .50  per  cent  in  the  fat 
and  sugar,  and  .25  per  cent  in  the  protein,  may  be  made  in  all  three 
food  elements.  If  indigestion  develops,  there  is  always  the  previous 
food  to  fall  back  upon. 

Between  the  eighth  and  the  twelfth  months,  the  changes  in  the 
composition  of  the  food  are  made  with  the  express  purpose  of  accus- 
toming the  baby  to  taking  whole  milk  instead  of  modified  milk. 
The  percentages  of  the  food  elements  should  be  gradually  altered  in 
such  a  way  as  to  approach  those  in  whole  milk.  For  example,  if  a 
baby  ten  months  old  is  taking  a  food  having  a  composition  of — 

Fat  3 .  50  Lactose  7  Protein  i .  50 


Feeding  in  Digestive  Disturbances  329 

the  change  should  be  somewhat  as  follows: — 

1.  Fat  4  Lactose  6.50  Protein  2.00 

2.  Fat  4  Lactose  6.00  Protein  2.50 

3.  Fat  4  Lactose  5.50  Protein  3.00 

4.  Whole  milk 

When  a  baby  goes  onto  whole  milk,  the  milk  sugar  usually  has  to 
be  reduced  in  greater  proportion  than  the  protein  is  increased.  This 
is  compensated  for  by  introducing  starch  into  the  food,  or  by  adding 
some  cereal  to  the  diet. 

In  strengthening  the  food  of  well  babies  who  are  gaining  satis- 
factorily in  weight,  the  changes  need  not  be  made  oftener  than  once 
a  week.  They  are  continued  until  the  baby  is  satisfied,  or  reaches 
a  food  of  full  strength  for  his  age.  If  the  food  is  being  strength- 
ened because  the  baby  is  not  gaining,  the  changes  should  be  made 
more  frequently,  twice  a  week  or  every  three  days. 

THE  FEEDING  OF  INFANTS  HAVING  DIFFICULTIES  OF  DIGESTION. 

To  this  group  belong  infants  who  have  previously  shown  symptoms 
of  indigestion,  and  infants  in  whom  the  management  of  the  feeding 
as  recommended  for  normal  infants  reveals  some  abnormality  of 
digestive  power.  In  such  cases  the  choice  of  food  is  much  more 
difficult,  and  there  is  a  demand  for  a  wider  use  of  the  resources  of 
milk  modification.  The  various  digestive  disturbances  which  may 
arise  in  the  course  of  artificial  feeding  are  described  and  discussed, 
in  detail  in  the  division  on  diseases  of  the  gastro-enteric  tract.  Cer- 
tain general  principles  of  treatment  having  a  definite  relation  to  the 
various  methods  of  cow's  milk  modification,  may,  however,  be  ad- 
vantageously discussed  here. 

CAUSES  OF  DIGESTIVE  DISTURBANCE.— The  manifesta- 
tions of  difficulty  in  digestion  in  an  infant  are  due  to  a  lack  of  bal- 
ance between  the  digestive  power  of  the  infant  and  the  composition 
of  its  food.  The  food  contains  fat,  carbohydrate  and  protein,  and 
the  digestive  idiosyncrasy  of  the  infant  is  usually  manifested  against 
one  or  more  of  these  food  elements.  In  certain  cases,  the  quantity 
of  food  as  a  whole  may  be  too  great  for  the  infant's  digestion.  Dis- 
turbances of  digestion,  therefore,  are  ultimately  traced  to  fat,  car- 
bohydrate, or  protein,  or  to  overfeeding  as  a  whole. 

SYMPTOMS  OF  DIGESTIVE  DISTURBANCE.— Various  symp- 
toms manifest  themselves  when  digestion  is  abnormal.  Among  the 
most  important  are  vomiting,  colic,  sour  eructation,  irritated  but- 
tocks, constipation,  diarrhea,  abnormal  stools,  and  failure  to  gain  in 
weight. 

DIAGNOSIS.  —  It  is  often  difficult  or  impossible  to  know  from 
the    symptoms    what  is    the    cause    of    the    trouble.     If  we   could 


330  Feeding 

deduce  from  the  symptoms  that  the  difficulty  Hes  in  the  digestion 
of  fat,  of  carbohydrate,  or  of  protein,  the  choice  of  the  modifi- 
cation promising  the  best  results  would  be  comparatively  easy.  The 
only  laboratory  method  of  value  available  is  the  micro-chemical 
examination  of  the  stools.  This  is  invaluable,  and  should  be  car- 
ried out  at  frequent  intervals  in  every  case  of  digestive  difficulty. 
More  valuable  than  the  symptoms  in  making  a  diagnosis,  are  the 
previous  feeding  records  of  the  case,  including  the  behavior  of  the 
infant  under  various  methods  of  feeding.  From  all  the  evidence, 
it  is  often  impossible  to  make  more  than  a  guess  as  to  which  is  the 
form  of  indigestion  present.  The  final  diagnosis  of  fat  indigestion, 
carbohydrate  indigestion,  protein  indigestion,  and  so  forth,  can  often 
only  be  made  j'rom  the  results  of  our  own  experiments  in  the  feeding 
of  the  case. 

In  the  meantime  we  have  to  treat  the  case.  We  wish,  as  soon  as 
possible,  to  relieve  symptoms  and  bring  about  a  gain  in  weight.  The 
only  thing  we  have  to  go  upon  is  the  clinical  symptoms,  but  we  must 
nevertheless  choose  our  initial  formula,  and  our  further  changes.  To 
do  this,  it  is  of  value  to  know  what  experience  has  shown  to  be  the 
best  method  of  guiding  the  feeding  in  the  face  of  certain  symptoms. 

CLINICAL  TYPES  OF  DISTURBANCE  SEEN  IN  ARTIFI- 
CIAL FEEDING. — It  is  convenient  to  know  what  methods  of  milk 
modification  to  try,  and  in  what  order  to  try  them,  in  certain  types 
of  cases  met  with  in  artificial  feeding.  The  following  clinical  t\Tpes 
will  be  considered: 

1.  Vomiting  the  only  symptom. 

2.  Undigested  movements  the  chief  symptom. 

3.  Green  or  discolored  movements  the  chief  symptom. 

4.  Failure  to  gain  weight  the  only  symptom. 

5.  Food  idiosyncrasy  against  milk. 

Vomiting  Cases. — This  clinical  type  may  be  due  to  indigestion 
from  any  one  of  the  three  food  elements.  Usually  when  carbo- 
hydrate is  the  cause  of  vomiting,  there  are  other  symptoms  beside. 
Vomiting  alone  is  most  apt  to  be  caused  by  fat  or  casein.  The 
vomiting  of  large  curds  immediately  after  nursing  points  toward  the 
casein.  Sour  vomiting  during  the  interval  points  toward  the  fat. 
In  many  cases  it  remains  always  impossible  to  recognize  the  original 
cause  of  the  vomiting,  because  the  symptom,  once  started,  is  apt 
to  persist  after  the  original  cause  has  been  removed.  The  stomach 
has  been  left  in  such  an  irritable  condition,  that  the  ordinary  pre- 
cipitation of  the  casein  in  the  stomach,  or  even  the  taking  of  any  food 
into  the  stomach,  will  cause  vomiting.  The  micro-chemical  exami- 
nation of  the  stools  for  fat  is  of  no  value  in  cases  of  this  type. 


Feeding  in  Digestive  Disturbances  331 

In  feeding  a  case  of  this  type,  try  first  a  food  with  a  fat  percentage 
of  zero.     For  example,  a  formula  containing — 

Fat  o  Dextri-maltose  6  Proteid  i .  50 

If  the  vomiting  is  reUeved,  it  is  a  case  of  fat  indigestion.  If  vomit- 
ing is  not  reHeved,  it  is  either  a  case  of  protein  indigestion  or  of 
habitual  vomiting  from  irritable  stomach.  In  young  babies,  who 
have  not  a  long  history  of  vomiting,  it  is  more  apt  to  be  due  to 
casein.  Even  with  habitual  vomiting  which  may  originally  have 
been  caused  by  fat  or  carbohydrate  indigestion,  the  precipitating 
cause  is  usually  the  casein.  The  various  methods  of  milk  modifica- 
tion influencing  protein  digestion  should  be  tried  one  after  the  other, 
in  the  following  order: 

1.  A  spHt  protein  formula,  such  as,  fat  i,  lactose  6,  whey 

protein  .go,  casein  .25. 

2.  The  same  with  lime  water  50%  of  the  milk  and  cream. 

3.  Some  other  alkah,  such  as  sodium  citrate.    For  example, 

fat  I,  lactose  6,  protein  1.50,  sodium  citrate  .40%  of 
the  milk  and  cream. 

4.  Lactic  acid  milk. 

In  making  experimental  changes  in  any  case  of  artificial  feeding, 
the  changes  should  not  be  made  oftener  than  every  three  days,  unless 
some  change  produces  immediately  new  symptoms  of  indigestion. 

Some  cases  will  do  well  with  small  quantities  at  shorter  inter- 
vals. If  all  these  measures  fail,  the  case  is  of  the  obstinate,  resis- 
tant type. 

As  additional  measures  in  cases  with  vomiting  as  the  chief  symp- 
tom, daily  gastric  lavage  is  of  great  value.  I  have  seen  a  few  cases 
of  this  type  reHeved  by  the  passage  of  the  duodenal  catheter.  In 
cases  in  which  there  is  vomiting  of  large  curds  immediately  after 
nursing,  the  alkalies  often  act  as  a  specific. 

Undigested  Movements. — This  cHnical  type  is  usually  due  either 
to  fat,  or  to  protein.  The  examination  of  the  stools  is  of  the  greatest 
diagnostic  value  in  these  cases.  If  the  stools  show  excessive  fat,  the 
treatment  is  that  of  fat  indigestion;  the  baby  may  be  started  on  a 
formula  containing — 

Fat  o  Dextri-maltose  6  Protein  2 ,  00 

and  carried  on  according  to  the  principles  described  under  indiges- 
tion from  fat.  If  the  stools  do  not  show  an  excess  of  fat,  the  various 
methods  of  influencing  protein  digestion  may  be  tried  in  the  follow- 
ing order: 

I.  The  use  of  starch.    Fat  2,  lactose  6.  protein  1.50.     Starch 
.75  may  be  given. 


332  Feeding 

2.  The  same  formula  may  be  boiled. 

3.  Lactic  acid  milk,  precipitated  casein,  or  a  combination 

may  be  tried. 
The  alkalies  are  less  valuable  in  this  type  of  protein  indigestion. 

Green  or  Discolored  Movements. — This  clinical  type  is  usually 
due  either  to  fat  or  to  carbohydrate  indigestion.  The  former  diag- 
nosis may  be  confirmed  by  the  results  of  the  micro-chemical  exami- 
nation of  the  stools  for  fat.  The  latter  diagnosis  is  often  confirmed 
by  the  other  symptoms  of  carbohydrate  indigestion,  namely,  vomit- 
ing, colic,  sour  eructations,  and  irritated  buttocks.  In  either  case, 
dextri-maltose  is  generally  to  be  preferred  as  the  extra  sugar.  Cases 
due  to  fat  should  be  started  on  some  such  formula  as — 

Fat  o  Dextri-maltose  6  Protein  i  .50-2.00, 

and  the  fat  increased  according  to  the  principles  of  treatment  in  fat 
indigestion.  Cases  due  to  carbohydrate  should  be  started  on  some 
such  formula  as — 

Fat  2  Dextri-maltose  4  Protein  i .  50-2 .  00, 

and  the  further  changes  made  in  accordance  with  the  principles  laid 
down  for  the  treatment  of  indigestion  from  carbohydrate. 

If  these  measures  fail,  whether  the  trouble  be  due  to  fat  or  carbo- 
hydrate, lactic  acid  milk,  or  precipitated  casein,  or  a  combination 
(albumin  milk)  should  be  tried  next. 

No  Symptoms. — In  this  type  the  baby  neither  vomits,  nor  shows 
any  marked  abnormality  in  the  microscopic  appearance  of  the  stools. 
It  simply  loses  weight,  or  fails  to  gain.  It  is  necessary  to  make 
sure  that  the  loss  of  weight  does  not  come  from  insufficient  food.  If 
not,  these  cases  are  usually  due  to  fat  indigestion.  They  are  best 
started  on  a  formula  containing  a  low  fat,  a  high  protein,  and  with 
the  extra  sugar  maltose,  such  as — 

Fat  o  Dextri-maltose  6  Protein  i .  50-2 .00 

The  further  treatment  is  carried  on  as  for  a  case  of  fat  indigestion. 

Food  Idiosyncrasy  Against  Milk. — It  is  very  common  to  hear 
of  cases  of  infants  who  supposedly  cannot  take  cow's  milk  in  any 
form.  In  the  majority  of  these  cases  it  is  not  true  that  cow's  milk 
cannot  be  digested  and  assimilated.  Most  of  them  are  really  cases 
which  have  some  marked  peculiarity  of  digestive  power  which  has 
defied  the  ordinary  resources  of  cow's  milk  modification. 

There  are,  however,  cases  of  true  food  idiosyncrasy  against  cow's 
milk.  These  cases  probably  represent  a  condition  in  which  the 
unsplit  cow's  milk  protein  is  for  some  reason  absorbed  into  the  cir- 
culation, and  the  disturbances  caused  thereby  represent  an  anaphy- 


Feeding  in  Digestive  Disturbances  333 

lactic  phenomenon.  Various  symptoms  are  observed  in  these  milk 
poisoning  cases.  The  commonest  symptom-complex  is  vomiting  and 
urticaria;  sometimes  diarrhea  is  seen.  The  positive  diagnosis  of 
the  idiosyncrasy  against  cow's  milk  can  be  made  by  means  of  the 
cutaneous  reaction.  If  the  skin  is  abraded  in  the  manner  used  for 
the  performance  of  the  von  Pirquet  tuberculin  test,  and  inoculated 
with  milk,  a  positive  reaction  will  be  obtained.  In  such  cases  artifi- 
cial feeding  is  impossible,  as  substitutes  for  cow's  milk  are  unsatisfac- 
tory.    Breast  milk  should  always  be  obtained. 

THE  FEEDING  OF  DIFFICULT  CASES— The  suggestions 
given  for  the  management  of  artificial  feeding  in  infants  showing 
difficulty  of  digestion,  will  not  solve  all  the  problems  presented. 
The  formulae  given  for  starting  cases  of  the  various  clinical  tj-pes 
encountered,  are  only  trial  formulae,  and  even  if  they  reheve  the 
symptoms,  often  do  not  meet  the  nutritive  requirements  of  the 
infant  to  an  extent  sufficient  to  permit  a  satisfactory  gain  in  weight. 
Even  after  the  use  of  the  trial  formula  considered  most  available 
in  a  particular  clinical  type,  the  nutritive  value  of  the  food  often 
has  to  be  increased  by  raising  the  percentages  of  some  of  the  food 
elements.  Increasing  the  quantity  of  a  food  element,  even  of  one 
which  has  previously  been  well  digested,  may  cause  some  new  type 
of  indigestion  to  develop.  Thus  there  are  always  a  certain  number 
of  difficult  cases  which  remain  to  tax  the  knowledge  and  resources 
of  the  physician. 

In  managing  such  cases,  every  eft'ort  should  be  made  to  reach 
the  ultimate  diagnosis.  The  changes  in  the  food  should  be  made 
in  such  a  way  as  to  give  the  physician  new  information  as  to  the 
digestive  pecuharities  of  the  infant.  For  this  reason  it  is  usually 
best  in  such  cases,  to  alter  the  percentage  of  only  one  food  element  at 
a  time,  or  to  introduce  only  one  new  method  of  cow's  milk  modification 
at  a  time,  in  order  that  the  deductions  based  upon  the  reaction  of 
the  infant  to  the  changes  shall  be  warranted. 

In  trying  the  various  available  methods  of  milk  modification  in 
these  difficult  cases,  the  physician  must  depend  upon  his  knowledge 
of  the  underlying  principles  of  artificial  feeding.  Success  will  depend 
on  the  skill  with  which  he  applies  this  knowledge  to  the  pecuharities 
of  the  case. 

At  all  times  in  the  course  of  a  resistant  feeding  case,  the  physi- 
cian knows  that  breast  milk  will  in  all  probabihty  be  the  best  means 
of  meeting  the  difficulties  with  which  he  is  confronted.  How  soon  he 
shall  resort  to  breast  milk  depends  on  the  severity  of  the  case,  and 
the  availability  of  a  wet-nurse. 

In  a  difficult  case,  the  physician  must  not  be  wholly  guided  by 
the  chnical  symptoms.     There  are  cases  in  which  the  symptoms  of 


334  Feeding 

indigestion  cannot  be  relieved  at  all,  or  can  be  relieved  only  by  the 
use  of  a  food  the  composition  of  which  is  not  of  sufficient  strength 
to  fulfil  the  nutritive  requirements  of  the  infant.  Nevertheless  in 
such  a  case  it  may  be  possible  to  find  a  combination  of  food  elements 
on  which  the  infant  will  gain  in  spite  of  the  symptoms.  Under  these 
circumstances  the  efforts  of  the  physician  to  relieve  the  symptoms 
should  not  involve  changes  in  the  composition  of  the  food,  but  should 
be  confined  to  those  methods  of  milk  modification  which  aim  at 
making  the  cow's  milk  more  digestible.  At  some  period  in  the 
course  of  every  resistant  feeding  case,  it  is  well  to  try  a  compara- 
tively strong  formula  without  reference  to  the  clinical  symptoms. 
This  will  sometimes  save  time  that  would  otherwise  be  wasted  in 
the  effort  to  render  the  infant  symptom-free. 

CLINICAL  INDICATIONS  FOR  THE  VARIOUS  METHODS 
OF  MODIFYING  COW'S  MILK 

The  subject  of  difficult  artificial  feeding  has  been  discussed  from 
the  point  of  view  of  the  clinical  symptoms,  with  suggestions  as  to 
the  methods  employed  in  meeting  the  difficulties  encountered.  It 
is  often  convenient  to  consider  the  subject  in  the  opposite  order, 
from  the  point  of  view  of  methods  of  modification,  with  suggestions 
as  to  the  clinical  indications  and  contraindications  for  each.  Such 
a  summary  is  given  here,  in  the  hope  that  it  may  prove  of  service 
to  physicians,  in  their  employment  of  the  resources  used  in  artifi- 
cial feeding. 

The  following  are  the  indications  and  contraindications  for  the 
various  methods  of  modifying  cow's  milk. 

1.  Milk  and  Cream  Dilution  with  the  Addition  oe  Lactose. — 
This  is  the  fundamental  method  of  varying  the  quantities  of  the 
three  food  elements.  It  is  indicated  in  all  cases  in  which  some  special 
method,  such  as  split  protein  or  lactic  acid  milk,  is  not  indicated. 
It  is  the  basis  of  the  feeding  of  normal  infants,  and  of  cases  of  fat 
or  carbohydrate  indigestion. 

2.  Starch. — Starch  may  be  advantageously  introduced  as  a  rou- 
tine into  the  food  of  well  infants  in  the  second  six  months.  The 
exact  age  when  starch  feeding  should  be  begun,  cannot  definitely 
be  stated.  It  is  best  not  to  use  it  as  a  routine  before  the  age  of 
six  months. 

With  sick  infants,  starch  is  theoretically  indicated  only  in  cases 
of  protein  indigestion.  It  is  the  method  of  first  choice  in  dealing 
with  protein  indigestion  in  the  latter  half  of  the  first  year.  It  is 
more  valuable  in  the  type  of  protein  indigestion  characterized  by 
undigested  movements,  than  in  the  form  characterized  by  vomiting. 

When  fat  or  carbohydrate  indigestion  is  the  fundamental  condition 
present,  there  is  usually  need  to  give  more  protein.     Starch  is  often 


Indications  for  Modifying  Cow's  Milk  335 

useful  in  such  cases,  especially  in  the  clinical  types  characterized  by 
undigested  movements,  or  by  green  or  discolored  movements. 

3.  The  Alkalies. — The  use  of  lime  water  as  a  routine  in  well 
babies  is  no  longer  considered  to  be  indicated.  The  alkalies  should 
be  used  only  to  meet  certain  definite  indications  in  disturbances  of 
digestion. 

The  alkalies  are  most  valuable  in  protein  indigestion  with  vomit- 
ing. In  the  particular  type  in  which  the  vomiting  of  curds  follows 
very  shortly  after  feeding,  an  alkali  will  often  immediately  relieve 
the  symptoms.  In  protein  indigestion,  it  should  first  be  given  in 
the  amount  necessary  to  delay  curd  formation  and  modify  the  char- 
acter of  the  curd;  if  it  fails  to  relieve  the  vomiting  in  this  amount, 
it  should  be  given  in  the  amount  which  prevents  precipitation  of  the 
casein  in  the  stomach. 

The  alkalies  are  also  very  useful  in  other  forms  of  indigestion, 
when  vomiting  is  a  prominent  symptom.  In  such  cases  the  vomit- 
ing often  becomes  persistent,  through  irritability  of  the  stomach. 
The  alkali,  given  in  sufficient  amount,  will  prevent  the  irritation  of 
a  sensitive  gastric  mucosa  by  the  precipitated  curd.  The  alkali 
may  be  used  in  combination  with  either  split  protein  formulae,  or 
starch-containing  formulae. 

There  are  no  indications  for  the  use  of  any  particular  one  of  these 
alkalies.  In  some  cases  hme  water  seems  to  work  best,  in  others 
sodium  citrate,  in  still  others,  sodium  bicarbonate.  One  cannot  tell 
beforehand  which  will  work  best. 

In  some  cases,  with  green  irritating  acid  stools,  an  excess  of  lime 
water,  as  25  per  cent  of  the  total  mixture,  has  given  clinical  evidence 
of  good  results. 

The  alkalies  have  no  contraindications,  but  have  not  given  evi- 
dence of  favorable  action  in  other  types  of  digestive  disturbance. 

4.  Peptonization. — This  method  of  modifying  milk  constitutes  a 
resource  to  be  tried  only  in  a  resistant  case,  in  which  other  more 
promising  methods  have  failed.  The  type  of  case  in  which  it  is 
occasionally  of  benefit,  is  that  characterized  by  persistent  vomiting. 

5.  Whey  Mixtures. — In  very  young  well  babies,  whey  mixtures 
are  often  of  advantage.  They  enable  us  to  give  more  protein  with- 
out risk  of  causing  symptoms.  Whey  mixtures  should  also  be  used 
in  the  feeding  of  premature  babies. 

Split  protein  formulae  are  indicated  in  protein  indigestion.  Pro- 
tein indigestion  is  much  commoner  in  young  babies  than  in  older 
ones.  The  split  protein  is'  the  method  of  choice  in  dealing  with  pro- 
tein indigestion  in  young  infants.  It  gives  the  best  results  in  cases 
characterized  by  vomiting. 

In  other  forms  of  indigestion  it  is  often  necessary  to  give  more 


336  Feeding 

protein  to  compensate  for  deficiency  in  the  power  of  assimilating 
fat  or  carbohydrate.  In  young  babies,  the  increased  casein  is  apt 
to  cause  vomiting.  The  whey  mixtures  enable  us  to  increase  the 
protein  without  increasing  the  casein. 

In  cases  of  persistent  vomiting  from  gastric  irritability  at  any 
age,  the  split  protein  combined  with  alkali  should  be  the  first  meas- 
ure chosen. 

The  split  protein  has  given  no  evidence  of  having  any  value  in 
those  types  of  indigestion  characterized  by  undigested  movements, 
or  by  the  absence  of  symptoms  other  than  loss  of  weight. 

There  are  two  important  contraindications  for  the  use  of  the  split 
protein.  These  are,  first,  acute  diarrheas,  and  second,  that  type 
of  indigestion  characterized  by  green  or  discolored  movements. 
Clinical  experience  has  shown  repeatedly  that  these  conditions  fare 
badly  when  fed  with  whey  mixtures.  In  both  conditions,  any  ten- 
dency toward  intestinal  fermentation  appears  to  be  increased,  pos- 
sibly because  the  soluble  protein  is  a  favorable  culture  medium,  or 
because  of  the  high  lactose  and  salt  content  of  the  whey.  The 
explanation  is  not  clear. 

6.  The  Carbohydrate. — Lactose  is  indicated  as  the  extra  carbo- 
hydrate to  be  added  to  milk  modifications  in  normal  babies,  and  in 
all  cases  with  comparatively  slight  disturbance  of  digestion.  It  is 
indicated  in  infectious  diarrhea  due  to  the  bacillus  of  dysentery, 
and  in  the  form  of  acute  diarrhea  due  to  abnormal  intestinal  fer- 
mentation, with  protein  decomposition  and  toxic  symptoms.  It 
should  be  used  in  all  cases  in  which  there  is  no  indication  for  maltose. 

Maltose  is  indicated  in  very  difficult  feeding  cases,  and  in 
severe  cases  of  malnutrition  and  atrophy.  It  is  part  of  the  routine 
in  the  treatment  of  chronic  indigestion  from  fat.  Carbohydrate  in- 
digestion is  most  frequently  seen  in  cases  fed  on  lactose  or  on  cane 
sugar;  in  such  cases,  maltose  is  indicated.  In  some  cases,  carbohy- 
drate indigestion  develops  in  babies  fed  on  maltose,  usually  in  exces- 
sive quantity.  In  such  cases,  changing  the  carbohydrate  to  lactose 
is  usually  beneficial. 

7.  Lactic  Acid  Milk.  —  This  is  indicated  as  a  therapeutic  meas- 
ure in  two  forms  of  diarrhea,  —  infectious  diarrhea  due  to  the  gas 
bacillus,  and  acute  diarrhea  with  toxic  symptoms  due  to  intestinal 
putrefaction. 

As  a  feeding  method,  lactic  acid  milk  is  a  valuable  resource  in 
certain  difficult  types.  It  should  be  tried  in  cases  of  fat  indiges- 
tion, when  the  usual  treatment  with  low  fat,  high  protein,  and  mal- 
tose, is  not  successful.  It  is  often  of  value  in  severe  carbohydrate 
indigestion.  It  is  most  useful  in  the  clinical  type  characterized  by 
green  or  discolored  movements,  and  should  be  the  first  method  tried 


Refusal  to  Take  Food  337 

in  such  types,  when  the  usual  methods  of  modifying  cow's  milk 
reveal  difficulties. 

It  is  usually  not  well  borne  when  vomiting  is  a  prominent  symp- 
tom, or  when  habitual  persistent  vomiting  has  developed. 

Precipitated  Casein. — This  is  used  only  in  difficult  feeding  cases. 
It  is  an  alternative  to  lactic  acid  milk,  or  may  be  used  in  combi- 
nation with  it  (albumin  milk).  The  indications  for  precipitated 
casein  are  the  same  as  those  of  lactic  acid  milk. 

Cooking. — This  measure  has  only  one  definite  indication,  namely, 
the  appearance  in  otherwise  normal  stools  of  large  casein  curds. 
It  may  be  tried  in  any  very  resistant  case. 

Homogenized  Milk. — The  indication  for  this  method  is  still  only 
theoretical.  The  method  was  developed  to  meet  certain  resistant 
cases  of  fat  indigestion,  in  which  the  baby  cannot  through  any  known 
method  of  modifying  milk  digest  and  absorb  enough  cow's  milk  fat 
to  meet  his  nutritive  requirements. 

INABILITY  OR  REFUSAL  TO  TAKE  FOOD  FROM  THE  BOTTLE 

Certain  babies  are  unable  to  take  their  food,  or  sufficient  food, 
from  the  bottle,  on  account  of  great  weakness.  In  these  cases  feed- 
ing must  be  forced.  If  the  difficulty  involves  their  power  of  suck- 
ing, but  not  their  power  of  swallowing,  the  food  is  best  given  with 
the  "Breck  Feeder."  This  consists  of  a  graduated  glass  tube,  drawn 
out  at  one  end  so  as  to  be  small  enough  to  be  fitted  with  a  small 
rubber  feeding-nipple.  A  compressible  rubber  cap  goes  over  the 
large  end  after  the  tube  is  filled.  The  nipple  is  put  in  the  baby's 
mouth,  and  its  presence  encourages  efforts  at  sucking.  If  these 
efforts  are  ineffectual,  the  nurse  compresses  the  rubber  cap,  gently 
forcing  the  milk  through  the  nipple  into  the  baby's  mouth,  and  thus 
helping  out  his  feeble  efforts.  It  is  always  best  to  continue  the 
sucking  reflex  in  these  cases. 

If  through  greater  weakness,  or  unconsciousness,  or  some  other 
'cause,  the  baby  is  unable  to  swallow,  he  must  be  fed  by  means  of 
gavage. 

In  some  cases,  not  at  all  uncommon,  babies  refuse  their  food. 
They  are  perfectly  able  both  to  suck  and  to  swallow,  but  they  do  not 
want  the  bottle,  and  resist  any  efi'ort  to  make  them  take  it.  They 
may  refuse  either  the  whole  or  a  part  of  a  feeding,  and  may  refuse 
some  or  all  of  their  daily  feedings.  This  symptom  may  of  course 
be  due  to  the  coming  on  of  one  of  the  common  acute  diseases.  Apart 
from  such  recognizable  diseases,  I  have  found  three  common  causes 
for  this  condition.  These  are,  first,  dentition,  stomatitis,  or  any 
localized  sore  mouth;  second,  early  scorbutus;  and  third,  the  baby 
may  become  tired  of  the  taste  of  his  food.     Stomatitis  and  scurvy 

22 


338  Feeding 

call  for  the  usual  treatment  of  those  diseases.  In  dentition,  apply- 
ing cold  water  to  the  gums  immediately  before  feeding  mil  often 
cause  the  baby  to  take  his  feedings  better.  If  the  baby  is  tired  of 
his  food,  some  minor  change  in  the  formula  wdll  often  satisfy  him; 
in  particular,  changing  the  extra  sugar  from  lactose  to  maltose,  is 
often  completely  curative. 

In  some  cases  of  refusal  of  food,  the  cause  may  not  be  discover- 
able, or  the  condition  may  prove  to  be  not  easily  remediable.  The 
physician  must  then  decide  to  what  extent  he  shall  allow  the  baby 
to  refuse  feedings  without  interference.  The  mother  is  often  much 
worried  by  this  symptom,  and  she  should  be  cautioned  against  tempt- 
ing the  child  with  food  in  the  intervals  between  his  regular  feed- 
ings. To  what  extent  the  child  shall  be  allowed  to  refuse  his 
feedings  depends  on  a  number  of  circumstances,  such  as  the  cause 
of  the  condition,  the  amount  of  food  refused,  and  the  general  con- 
dition of  the  child.  In  general,  temporary  conditions  of  short  dura- 
tion require  no  interference.  When  the  condition  is  of  longer  dura- 
tion the  child's  nutrition  must  not  be  allowed  to  suffer  too  much. 
Sometimes  one  tube  feeding  will  reheve  the  condition.  Usually, 
when  the  child's  nutrition  begins  to  suffer,  I  am  accustomed  to  order 
that  the  child  shall  take  a  certain  minimum  quantity  of  food  daily. 
If  he  has  not  taken  the  right  proportion  of  this  minimum  by  a  cer- 
tain hour  each  day,  tube  feedings  are-  to  be  used  to  the  extent  of 
insuring  the  taking  of  the  desired  minimum. 

In  dentition,  acute  disease,  and  similar  conditions,  the  digestive 
power  of  the  infant  is  frequently  lowered,  and  his  refusal  to  take 
his  feedings  is  Nature's  way  of  guarding  his  digestive  system  from 
an  overload.  Great  harm  can  be  done  in  such  cases,  by  forcing  the 
feeding. 


IV.     FEEDING  IN  THE  SECOND  YEAR 

FEEDING  OF  HEALTHY  INFANTS 

There  is  no  subject  about  which  so  much  ignorance  prevails,  as 
the  feeding  of  infants  during  the  second  year  of  life.  It  has  become 
fairly  well  known  that  cow's  milk  has  to  be  carefully  modified  and 
prepared  for  infants  in  their  first  year,  but  as  soon  as  the  twelfth 
month  has  been  passed,  and  the  infants  are  able  to  digest  whole 
milk,  there  seems  to  be  a  very  prevalent  idea  that  they  can  digest 
almost  anything.  A  few  children  are  underfed  in  the  second  year, 
but  the  great  majority  are  overfed,  with  badly  prepared,  unsuitable 
food  carelessly  given  at  improper  intervals.  The  acute  diarrheas 
so  prevalent  in  the  summer  months^  are  very  common  in  infants 
between  one  and  two  years  of  age,  so  much  so  that  the  "second 
summer"  has  come  to  be  a' much  dreaded  period.  The  dangers  of 
the  second  summer  are  mainly  due  to  improper  feeding,  and  can  be 
entirely  prevented  by  proper  management. 

Among  the  mistakes  most  commonly  made  at  this  period  of  life, 
is  the  practice  of  allowing  the  infants  to  eat  between  meals.  As 
long  as  the  feeding  of  the  infant  involves  the  labor  of  administering 
the  breast  or  the  bottle,  mothers  are  less  likely  to  err  in  this  par- 
ticular; as  soon  as  the  baby  is  able  to  take  food  in  its  hand,  and  eat 
it,  this  involving  no  labor  on  the  part  of  the  mother,  it  begins  to 
get  crackers,  cookies,  or  a  slice  of  bread  and  butter  at  all  times, 
this  being  regarded  as  a  legitimate  means  of  keeping  it  quiet.  Not 
only  crackers,  but  drinks  of  milk  are  given  between  meals,  under 
the  idea  that  drink  is  not  food.  As  a  result  of  all  this,  the  child 
begins  to  take  less  food  at  meals,  and  its  feeding  becomes  a  con- 
tinuous nibbling,  which  keeps  its  digestive  system  in  a  state  of  con- 
stant stimulation,  with  most  ruinous  results.  Children  in  the  second 
year  should  never  be  allowed  to  eat  between  meals.  Even  the  drink 
of  milk,  or  the  "educator"  cracker  is  harmful. 

A  second  mistake,  is  irregular  hours  for  meals,  or  improper  inter- 
vals between  meals.  This  error  is  sometimes  committed  through 
carelessness,  and  sometimes  in  the  effort  to  make  some  of  the  infant's 
meals  coincide  with  those  of  the  parents,  so  that  the  infant  can  come 
to  table,  sitting  in  its  "high  chair."  Beside  the  tax  on  the  infant's 
digestive  power  which  such  irregularity  of  feeding  intervals  entails, 
the  fact  that  the  baby  comes  to  table  leads  to  the  practice  of  giving 
it  "tastes"  of  the  food  provided  for  the  rest  of  the  family.  The  idea 
that  little  tastes  of  these  various  foods  can  do  no  harm,  is  a  very 


340  Feeding 

mistaken  one.  In  this  practice  the  father  is  usually  a  more  frequent 
offender  than  the  mother,  a  father  often  being  very  proud  that  his 
boy  of  fifteen  months  likes  the  same  articles  of  diet  as  himself.  An- 
other evil  in  having  the  infant  take  its  meals  with  its  parents,  is 
that  special  care  is  not  devoted  to  the  preparation  of  the  food  for 
the  infant,  but  many  articles  of  diet  suited  only  to  the  adult  are 
given  to  the  infant  under  the  mistaken  theory  that  if  he  is  healthy, 
they  can  do  no  harm. 

An  infant  in  the  second  year  should  have  his  meals  by  himself, 
at  regular  and  proper  intervals.  There  is  no  reason  why  he  should 
not  eat  with  older  children,  when  their  feeding  time  falls  at  the 
same  hour.  The  infant's  food  should  be  specially  prepared  for  him. 
If  the  family  cannot  manage  a  separate  dietary  for  their  young 
children  and  the  older  members,  it  is  better  that  the  older  members 
should  eat  what  is  good  for  the  children,  than  that  the  children 
should  be  forced  to  eat  what  the  older  members  like. 

One  common  mistake  made  in  the  feeding  of  infants  in  their  second 
year,  is  that  they  are  not  given  sufficient  milk.  As  they  begin  to 
take  other  foods,  some  of  which  they  often  like  better  than  milk, 
the  quantity  of  milk  in  their  diet  is  gradually  and  often  uncon- 
sciously cut  down.  Milk  should  be  the  basis  of  the  infant'' s  diet  through- 
out the  second  year.  The  popular  idea  that  many  children  cannot 
take  milk,  has  no  foundation  in  fact,  food  idiosyncrasy  against  milk 
being  rare.  The  other  articles  of  diet  should  always  be  additional, 
and  should  never  take  the  place  of  milk. 

Another  fault  in  the  feeding  of  infants  is  the  giving  of  sweets. 
This  I  believe  to  be  one  of  the  commonest,  if  not  the  commonest 
cause  of  disturbed  nutrition  in  all  periods  of  childhood  after  the 
end  of  the  first  year.  The  symptoms  of  excessive  sugar  ingestion 
develop  so  insiduously,  that  they  are  rarely  recognized  as  pointing 
toward  the  digestive  system.  Candy,  even  at  meals,  should  never 
be  given  to  infants  in  the  second  year.  I  am  inclined  to  go  much 
farther  than  this,  and  do  not  believe  that  sugar  should  be  added 
to  the  diet  at  all.  It  may  be  true  that  the  majority  of  children 
can  take  reasonable  quantities  of  cane  sugar  without  harm,  but 
sugar  is  by  no  means  a  necessary  component  of  the  child's  diet. 
The  child  gets  all  the  carbohydrate  it  requires  in  the  lactose  of  its 
milk,  in  the  starch  of  its  bread  and  cereals,  and  in  the  fruits  which 
are  added  later.  Sugar  can  be  absolutely  dispensed  with,  without 
harm.  The  trouble  with  sugar  is  that  young  children  like  it,  and 
once  having  tasted  it,  want  more  and  more  of  it.  Under  these 
circumstances,  it  is  very  difficult  to  keep  it  in  moderation,  for  the 
young  child  well  knows  how  to  get  what  it  likes,  and  is  an  adept 
at  bullying  its  parents  into  giving  it  what  it  likes.  Once  having 
tasted  sweets,  it  is  very  apt  to  begin  to  refuse  to  take  its  other  arti- 


Feeding  in  the  Second  Year  341 

cles  of  diet,  and  the  feeding  of  the  child  becomes  a  struggle,  a  con- 
flict in  which  the  child  is  apt  to  win.  If  children  do  not  know  the 
taste  of  sugar,  much  trouble  is  avoided. 

Underfeeding  is  sometimes  met  with  in  the  second  year.  The 
commonest  cause  is  keeping  the  infant  too  long  on  the  breast  only, 
or  on  an  exclusively  milk  diet. 

The  various  solid  articles  of  diet  given  in  the  second  year  should 
be  added  gradually,  one  at  a  time,  and  at  first  in  very  small  quanti- 
ties. Sometimes  the  expansion  of  the  diet  list  is  attended  with 
considerable  difficulty.  The  children  refuse  to  chew  and  swallow 
solid  foods,  and  are  thoroughly  satisfied  with  milk.  In  such  a  case, 
it  is  often  well  for  a  time  for  the  child  to  have  its  meals  with  its  parents 
or  with  older  children,  and  to  see  them  eat.  Children  learn  rapidly 
by  imitation.  They  should  be  given  every  opportunity  to  eat  solid 
food,  but  should  not  be  forced.  Milk,  for  a  time,  must  be  kept  in 
the  background,  and  the  more  solid  articles  given  first.  Often  much 
time  and  patience  are  required  before  they  will  eat. 

WEANING  FROM  THE  BOTTLE.— At  the  beginning  of  the 
second  year,  weaning  from  the  bottle  should  be  started.  This  is  some- 
times a  matter  of  considerable  difficulty,  the  infants  refusing  abso- 
lutely to  take  milk  from  a  cup.  It  can  only  be  accomplished  by 
patience.  It  is  best  to  begin  with  the  early  morning  feeding,  and 
then  gradually  to  extend  the  use  of  the  cup  to  the  other  feedings. 
The  cup  should  be  offered,  and  if  refused,  the  bottle  should  not  be 
given  till  after  an  interval  of  fifteen  or  twenty  minutes.  It  is  advis- 
able not  to  begin  to  add  much  solid  food  to  the  diet  until  weaning 
from  the  bottle  has  been  started.  The  use  of  the  bottle  at  the  lo 
P.  M.  feeding  may  be  continued,  for  convenience,  until  this  feeding 
is  omitted.  Except  for  this  feeding,  weaning  from  the  bottle  should 
be  completed  before  the  fifteenth  month. 

PREPARATION  OF  FOODS  FOR  INFANTS  IN  THE  SEC- 
OND YEAR.  Milk. — In  the  majority  of  cases  the  milk  used  as 
the  basis  of  the  diet  in  the  second  year,  does  not  require  modifica- 
tion. The  same  precautions  should  be  taken  as  to  the  quality  of 
the  milk  used.  The  decision  as  to  whether  the  milk  shall  be  pasteur- 
ized is  to  be  made  on  the  same  grounds  as  in  the  first  year.  Cream 
should  not  be  given,  except  in  special  cases,  such  as  constipation. 

Zwieback. — -This  is  somewhat  more  digestible  than  bread.  The 
unsweetened  variety  should  always  be  used.  The  zwieback  made 
by  the  National  Biscuit  Company  is  excellent. 

Cereal  Jellies. — Oatmeal,  four  ounces,  is  added  to  one  pint  of 
water,  and  boiled  for  three  hours  in  a  double  boiler.  Enough  water 
is  added  to  form  a  thin  paste  when  cooking  is  completed.     While 


342  Feeding 

hot,  this  is  forced  through, a  colander,  and  a  semi-solid  mass  is  formed. 
Only  the  regular  Scotch  oatmeal,  not  rolled  oats  or  any  similar  prepa- 
ration, should  be  used. 

Barley  jelly  and  wheat  jelly  are  made  in  the  same  way,  using 
barley  flour,  or  cracked  wheat  instead  of  oatmeal. 

Salt  should  always  be  added  to  cereal  jellies,  but  they  should  be 
given  without  sugar. 

Beef  Juice. — Broil  a  round  steak  very  rare,  cut  into  small  pieces, 
place  in  a  lemon-squeezer  or  meat  press,  and  press  out  the  juice;  add 
a  little  salt. 

Broths. — Take  one  pound  of  meat  free  from  fat,  and  cook  for 
three  hours  in  a  quart  of  water,  adding  a  Uttle  water  from  time  to 
time.  When  the  cooking  is  completed,  there  should  be  a  pint  of 
broth.     Let  the  broth  cool,  remove  the  fat,  strain,  and  add  salt. 

Scraped  Beef. — Broil  a  round  steak  very  rare.  Split  the  steak, 
and  scrape  out  the  pulp  with  a  dull  knife. 

Cereals. — Oatmeal  and  hominy  should  be  strained  to  make  a 
jelly,  until  toward  the  end  of  the  second  year.  Farina,  cream  of 
wheat,  and  wheatena  should  each  be  cooked  two  hours,  and  need 
not  be  strained.  All  cereals  should  be  cooked  with  salt,  but  served 
without  sugar. 

Egg. — Soft  boiled,  poached,  or  coddled  are  the  only  ways  of  pre- 
paring egg  permissible  for  young  children. 

Junket.— To  a  pint  of  milk  add  one  tablespoon  of  essence  of 
pepsin  or  liquid  rennet,  or  a  junket  tablet.  Heat  to  ioo°  F.  Allow 
to  stand  until  the  curd  is  set,  then  place  and  keep  on  ice. 

DIET  FROM  THE  TWELFTH  TO  THE  FIFTEENTH 
MONTH.^ — The  following  schedule  may  be  adopted  for  the  feeding 
of  an  infant  from  the  twelfth  to  the  fifteenth  month: 

Table  37 
Feeding  from  the  Twelfth  to  the  Fifteenth  Month 

FOUR  OR  FIVE  MEALS  DAILY 

6:30  A.M.     (Minimum)     Milk,  8  ounces. 

Zwieback,  gradually  increasing  to  one  whole  piece. 
(Maximum)      Stale  bread  and  butter,  one  piece,  in  place  of  zwieback. 

9:00  A.  M.     The  juice  of  one-half  orange. 

10:00  A.  M.      (Minimum)      Milk,  8  ounces. 

Zwieback,  increasing  to  one  whole  piece. 
(Maximum)     Oatmeal  or  barley  jelly,  one  tablespoon,  increasing  to  two. 
tablespoons. 


Feeding  in  the  Second  Year  343 

Table  37 — Continued 
2:00  P.  M.      (Minimum)      Milk,  8  ounces. 

Zwieback,  increasing  to  one  whole  piece. 
(Maximum)     Beef  juice,  one  increasing  to  two  ounces,  or  beef,  mutton, 
or  chicken  broth,  one  increasing  to  four  ounces. 
Scraped   rare   beef   mixed   with   stale   bread   crumbs,   and. 
moistened  with  beef  juice,  beginning  with  one  teaspoon, 
and  increasing  to  a  tablespoon. 

6:00  P.M.      (Minimum)      Milk,  8  ounces. 

Cereal  jelly,  one  increasing  to  two  tablespoons. 
(Maximum)     Zwieback,  or  stale  bread  and  butter. 

The  first  two  additions  to  the  child's  diet  are  zwieback  and  orange 
juice.  I  have  found  zwieback  the  most  digestible  form  of  starch- 
containing  food  which  can  be  given  at  this  time.  It  can  be  soaked 
in  milk  at  first,  but  later  the  children  usually  prefer  to  hold  it  in 
the  hand  and  nibble  at  it.  Only  a  small  piece  should  be  given  at 
the  beginning,  and  later  increased.  During  the  last  part  of  the 
first  year,  babies  are  weaned  from  the  bottle,  or  are  gradually  brought 
from  modified  milk  to  whole  milk.  While  they  are  still  on  modified 
milk,  starch  should  be  given  in  small  quantities  by  using  barley 
water  as  a  diluent  in  their  milk.  Zwieback  may  be  given  even  then,  if 
they  are  a  year  old,  or  seem  hungry.  In  any  case,  zwieback  should  be 
begun  when  they  go  onto  whole  milk,  provided  that  they  have  teeth. 

Orange  juice  may  often  be  advantageously  given  before  the  child 
is  a  year  old.     As  a  routine,  it  should  be  begun  at  one  year. 

The  schedule  provides  for  a  minimum  and  a  maximum  diet  at 
each  meal.  The  minimum  diet  refers  to  what  is  added  to  the  diet 
in  the  beginning,  the  zwieback  being  given  first,  and  then  the  cereal 
jelly  at  supper.  The  maximum  diet  shows  the  diet  reached  at  the 
end  of  the  period  by  gradual  additions.  The  morning  cereal  should 
be  added  first,  then  the  beef  juice  or  broth,  then  the  bread  and  butter, 
finally  the  scraped  beef. 

Many  authorities  begin  to  give  egg  during  this  period,  substituting 
it  for  the  scraped  beef.  In  my  experience  scraped  beef  is  less  likely 
to  cause  disturbance  than  egg  at  this  period  of  life. 

DIET  FROM  THE  FIFTEENTH  TO  THE  EIGHTEENTH 
MONTH. — The  following  schedule  may  be  used  during  this  period: 

Table  38 
Feeding  from  the  Fifteenth  lo  the  Eighteenth  Month 

FOUR  MEALS  DAILY     ' 

6.30  A.  M Milk,  8  to  10  ounces. 

Zwieback,  or  bread  and  butter. 

9:00  A.  M. The  juice  of  one  orange. 

10:00  A.  M.      (Minimum)      Milk,  6  to  8  ounces. 

Cereal  (oatmeal  or  hominy)  strained,  two  to  three  table- 
spoons, with  milk. 
Zwieback,  or  stale  bread  and  butter. 
(Maximum)     Egg,  one  (soft  boiled,  poached,  or  coddled). 


344  Feeding 

Table  38 — Continued 

2  :oo  P.  M.      (Minimum)      Milk,  6  to  S  ounces. 

Beef  Juice,  or  mutton,  chicken,  or  beef  broth  with  rice  or 

stale  bread  broken  in. 
Scraped  rare  beef  with  bread  crumbs,  one  tablespoon. 
Bread  and  butter. 
(Maximum)      Stewed  prune  pulp,  baked  apple,  or  apple  sauce. 

6:00  P.  M Milk.. 

Bread  and  butter,  or  bread  and  milk. 

Cereal,  (farina,  cream  jjt  wheat,  or  wheatena),  one  increas- 
ing to  three  tablespoons. 

The  only  new  articles  not  added  to  the  maximum  diet  of  the  pre- 
ceding period,  are  the  egg,  the  cereal  instead  of  cereal  jelly  at  supper, 
and  the  fruit.  The  cereal  and  egg  may  be  added  first,  but  the  fruit 
should  be  tried  very  cautiously. 

DIET  FROM  THE  EIGHTEENTH  TO  THE  TWENTY- 
FOURTH  MONTH. — The  following  schedule  may  be  used  during 

this  period: 

Table  39 

Feeding  from  the  Eighteenth  to  the  Twenty-fourth  Month 

FOUR  ILEALS  DAILY 

7  :oo  A.  M Milk,  8  to  10  ounces. 

Bread  and  butter. 

Cereal. 

Egg. 

9:00  A.  M Orange  juice. 

II  :00  A.M.      (Minimum)      Milk. 

Bread  and  butter. 

Chicken,  beef,  or  mutton  broth  with  rice  or  stale  bread. 
(Maximum)      Custard,  or  cornstarch,  or  plain  rice  pudding,  or  junket. 

2 130  P.  M.      (Minimum)      ]Milk. 

Bread  and  butter. 

Scraped  beef,  or  the  heart  of  a  lamb  chop  cut  up  fine,  or 

chicken. 
Baked  apple,  or  apple  sauce. 
(Maximum)      Spinach,  or  squash,  or  stewed  carrots,  or  mashed  cauliflower. 
Baked  potato  added  toward  end  of  the  second  year. 

6:00  P.  M Milk. 

Cereal. 

Bread  and  butter. 

Certain  changes  in  the  arrangement  of  the  meals  are  made  in 
this  schedule,  in  preparation  for  the  child  having  later  three  prin- 
cipal meals  daily.  Babies  at  this  age  are  apt  to  sleep  later  in  the 
morning,  and  the  first  meal  becomes  a  regular  breakfast  at  seven 
o'clock.  The  second  meal  is  made  relatively  light,  and  the  third 
meal  will  later  become  the  dinner.  The  new  articles  should  be  only 
gradually  added  to  the  diet.  Potato  should  not  be  given  before 
the  twenty-first  month,  and  sometimes  cannot  be  digested  till  the 
end  of  the  second  year. 


Feeding  ix  the  Second  Year  345 

FEEDING  IN  DIFFICULT  CASES 

The  tendency  to  chronic  digestive  disturbance  and  malnutrition 
has  not  been  outgrown  when  the  infant  reaches  the  second  year  of 
its  life.  Its  digestive  apparatus  is  still  relatively  undeveloped,  and 
requires  the  most  digestible  foods.  While  the  number  of  cases  of 
difficult  nutrition  met  with  in  the  second  year  is  smaller  than  in 
the  first,  such  cases  are  by  no  means  uncommon.  Some  of  them  are 
seen  in  infants  whose  nutrition  has  been  a  matter  of  difficulty  from 
birth,  and  who  have  been  brought  through  the  first  year  only  by 
the  exercise  of  the  greatest  care.  Others  have  had  their  digestive 
power  badly  damaged  by  improper  feeding.  Still  others  enter  the 
second  year  apparently  normal,  and  with  every  promise  of  normal 
development,  but  soon  after  weaning  begin  to  do  badly. 

The  factor  of  individual  variation  in  digestive  power  still  plays 
an  important  part  in  the  second  year.  A  diet  which  is  exactly 
suited  to  the  majority  of  infants  may  be  wholly  unsuitable  to  an 
infant  with  impaired  digestive  power.  Infants  may  enter  the  second 
year  with  impaired  digestive  power,  and  although  given  an  average 
diet,  may  yet  be  relatively  overfed.  On  the  other  hand,  many  of 
the  cases  of  difficult  nutrition  in  the  second  year  entered  this  period 
of  Hfe  with  normal  digestive  power,  and  their  trouble  is  due  to  inju- 
dicious feeding  after  weanmg.  It  is  often  difficult  in  a  given  case 
to  say  which  factor  predominates,  weakness  of  digestive  power,  or 
faulty  feeding. 

There  are  two  clinical  types  of  chronic  disturbance  which  are 
especially  common  at  this  period.  In  the  first,  the  symptoms  are 
very  insidious,  and  do  not  point  very  directly  at  the  digestive  appa- 
ratus. In  these  cases,  loss  of  weight  is  not  marked,  but  the  children 
become  generally  run  down;  they  become  pale,  and  their  muscles 
become  flabby.  Loss  of  appetite  is  a  prominent  symptom.  There 
is  often  a  chronic  cough,  which,  with  the  other  symptoms,  leads  the 
parents  to  suspect  tuberculosis.  In  other  cases  of  this  t\^e,  attacks 
of  abdominal  pain  are  a  prominent  feature.  These  patients  usually 
have  coated  tongues,  prominent  abdomens,  and  clay  colored  stools. 

The  cause  of  this  type  is  relative  overfeeding  with  carbohydrate. 
It  is  the  type  of  indigestion  seen  in  the  candy  eaters,  or  in  children 
who  eat  an  excess  of  sweets.  In  some  children  any  sugar  in  the 
diet  may  be  an  excess  and  cause  this  clinical  picture  to  develop.  In 
other  children,  no  sugar  may  be  given,  but  the  carbohydrate  foods 
may  be  in  relative  excess.  Children,  who,  on  taking  solid  food,  take 
too  little  milk,  or  children  who  eat  between  meals,  are  common  sub- 
jects of  this  t>'pe  of  nutritional  disturbance. 

This  type  is  not  really  difficult,  or  resistant  to  proper  treatment. 
The  difficulty  lies  in  recognizing  it.     All  sugar  should  be  cut  out  of 


346  Feeding 

the  diet,  and  the  carbohydrate  should  be  reduced  to  a  minimum.  I 
usually  cut  out  all  cereals,  the  diet  being  milk,  beef  juice,  scraped 
beef,  a  little  bread  or  zwieback,  and  in  older  babies,  egg.  Small 
doses  of  tincture  of  nux  vomica  are  often  of  service  in  combating 
the  persistent  refusal  to  take  food,  which  is  sometimes  a  trouble- 
some feature  in  these  cases. 

The  second  type  is  much  more  resistant  and  difficult  to  treat. 
First  there  is  only  failure  to  gain  in  weight,  then  increasing  loss. 
Sometimes  these  cases  may  even  go  on  to  severe  atrophy.  The 
symptoms  of  gastro-intestinal  disturbance  are  not  marked.  The 
stools  are  often  abnormal  in  color,  but  are  usually  large,  smooth,  and 
rather  dry,  with,  a  peculiarly  foul  odor.  Microchemical  examination 
usually  reveals  a  deficiency  in  the  absorption  of  the  fat.  The  babies 
having  this  disorder  are  apt  to  be  very  irritable  and  cross,  and  this 
is  increased  when  more  food  is  given.  They  often  have  a  slight 
fever,  which  disappears  when  their  diet  is  restricted. 

The  cause  of  this  condition  is  overfeeding.  The  original  damage 
cannot  usually  be  traced  to  any  one  food  element.  Cases  of  this 
type  are  seen  most  frequently  in  children  who  have  been  overfed 
in  all  respects,  who  have  a  highly  varied  diet,  including  tastes  of  rich 
foods.  The  disease  manifests  itself  in  a  general  deficiency  of  diges- 
tion and  absorption,  which  appears  most  striking  in  the  case  of  the 
fats.     Carbohydrates  also  are  poorly  borne. 

This  type  of  disturbed  nutrition  is  difficult  to  treat.  When  the 
diet  is  restricted,  the  infants  may  be  freed  from  the  irritability  and 
slight  fever,  and  the  character  of  the  stools  may  improve,  but  they 
lose  weight  rapidly.  When  additions  are  made  to  the  diet,  the 
symptoms  return,  without  gain  in  weight.  The  main  principle  of 
treatment  is  restriction  of  fat  and  carbohydrate.  To  what  extent 
this  shall  be  carried  depends  on  the  severity  of  the  case.  In  a  severe 
case  of  this  type,  all  carbohydrate  foods,  such  as  bread,  zwieback, 
and  cereals,  must  be  prohibited,  and  milk  must  for  a  time  be  stricken 
from  the  diet,  which  consists  of  beef  juice  and  scraped  rare  beef. 
Many  cases  improve  on  this  diet,  but  it  cannot  be  continued  long. 
Some  cases  seem  to  become  worse.  The  next  addition  is  maltose, 
given  first  in  6  per  cent  solution.  Then  fat-free  milk  containing 
6  per  cent  maltose  is  added.  The  rest  of  the  treatment  is  the  very 
gradual  adding  of  fat  to  the  milk,  and  starch  to  the  diet,  proceeding 
very  slowly  and  cautiously,  with  frequent  examinations  of  the  stools. 

Occasionally  a  definite  intolerance  toward  fat  or  protein  of  cow's 
milk,  like  that  seen  in  the  first  year,  occurs  in  the  second  year.  In 
such  cases  the  milk  must  be  modified  as  in  the  feeding  of  similar 
cases  in  the  first  year. 


V.  FEEDING  AFTER  THE  SECOND  YEAR 

The  diet  after  the  expiration  of  infancy,  gradually  approaches 
that  of  the  adult.  It  must  be  remembered,  however,  that  during 
the  entire  period  of  childhood,  the  digestive  functions  remain  un- 
developed in  comparison  with  the  adult.  Therefore  throughout 
childhood  certain  kinds  of  food,  which  lay  the  greatest  tax  on  the 
powers  of  digestion  should  be  avoided.  As  the  child  grows  older, 
the  diet  should  be  gradually  enlarged,  but  must  always  be  restricted. 
Many  parents  believe  that  children  need  a  great  variety  in  their 
diet.  This  is  not  true,  but  restrictions  are  difficult,  if  too  much 
variety  has  once  been  allowed.  The  following  table  shows  in  a  form 
convenient  for  reference,  the  foods  which  are  allowed,  and  those 
which  are  forbidden  during  the  greater  part  of  childhood.  Of  course, 
toward  the  end  of  childhood,  the  restrictions  can  be  gradually  relaxed. 


Table  40 
Diet  List  for  Children 


ALLOWED 


Milk 

Cream 

Stale  bread 

Graham  bread 

Crackers  and  biscuits 

Eggs  (not  fried) 

Cooked  cereals 

Butter 

Plain  soups 

Beef  juice 

Beefsteak 

Roast  beef 

Roast  lamb 

Mutton  chop 

Chicken 

Fish,  baked  or  boiled 

Potatoes  (not  fried) 

Rice 

Spinach 

Asparagus  tips 

Stewed  celery 

String  beans 

Carrots 

Fresh  peas 

Squash 

Mashed  cauliflower 

Boiled  onions 

Junket 

Custard 

Cornstarch  pudding 

Rice  pudding  (without  raisins) 

Ice  cream  (rarely) 

Oranges 

Baked  apples 


FORBIDDEN 

Tea 

Coffee 

Cocoa 

Soda  water 

Hot  bread  and  rolls 

Griddle  cakes 

Sweet  cakes 

Ready-to-serve  cereals 

All  fried  food 

Ham 

Pork 

Sausage 

Salt  fish 

Fried  fish 

Corned  beef 

Dried  beef 

Meat  stews 

Meat  dressings 

Kidney 

Liver 

Goose 

Duck 

Fried  potatoes 

Cabbage 

Raw  or  fried  onions 

Tomatoes 

Beets 

Egg  plant 

Green  corn 

Lettuce 

Cucumbers 

Raw  celery 

Radishes 

Salads 


348  Feeding 

Table  40 — Continued 

Apple  sauce  Candy 

Stewed  prunes  Pies 

Peaches  Tarts 

Pears  All  pastry 

Grapes  (without  seeds)  Preserves 

Nuts 

Dried  fruits 

Raw  apples 

Bananas 

Many  authorities  believe  that  four  meals  should  be  given  daily 
during  the  third  year,  and  even  until  the  sixth  year.  I  beUeve  that 
with  most  healthy  children,  three  meals  are  better.  The  children 
have  better  appetites,  digest  better,  and  their  daily  schedule  of 
exercise,  airing,  and  naps,  is  more  easily  arranged.  Nevertheless, 
especially  in  the  third  year,  many  children  will  thrive  better,  if  a 
light  lunch  be  given  at  about  3  or  3.30  P.  M.  With  dehcate  children, 
this  light  fourth  meal  often  has  to  be  continued  until  the  seventh 
year.  This  lunch  should  consist  of  a  glass  of  milk,  and  some  crack- 
ers, or  a  cup  of  broth  and  zwieback. 

The  meals  for  the  earlier  years  of  childhood  should  be  arranged 
■as  follows: 

Breakfast — 7  to  8  A.  M.  Cereal  with  milk;  eggs;  bread  and 
butter,  or  biscuit  and  butter;  a  drink  of  milk.  On  certain 
days  a  lamb  chop  or  some  hashed  chicken  may  be  sub- 
stituted for  the  egg. 

Dinner — 12  o'clock.  Soup  or  broth;  meat,  or  when  meat  is 
given  for  breakfast,  fish  or  egg;  potato;  vegetable;  bread 
and  butter;  baked  apple,  apple  sauce,  or  prunes;  milk. 

Supper — 5.30  to  6  P.  M.  Cereal;  zwieback  or  bread  and 
butter;  junket,  custard  or  pudding;  milk. 


DIVISION  V 

DISEASES  OF  THE  GASTRO-ENTERIC 

TRACT 

The  diseases  of  the  gastro-enteric  tract  may,  with  certain  sHght 
moditications,  be  classified  according  to  the  plan  based  on  etiology 
described  in  Division  II. 

CLASSIFICATION  OF  THE  DISEASES  OF  THE 
GASTRO-ENTERIC  TRACT 

I.  MALFORMATIONS 
II.  TRAUMATIC  MECHANICAL  INJURIES 

1.  Foreign  bodies 

2.  Corrosive  gastritis 

HI.  MECHANICAL  CONDITIONS  OF  INTERNAL  ORIGIN 

1.  Stenosis  of  the  pylorus 

2.  Spasm  of  the  pylorus 

3.  Dilatation  of  the  stomach 

4.  Contraction  of  the  stomach 

5.  Dilatation  of  the  colon 

6.  Intussusception 

7.  Volvulus 

8.  Hernia 

9.  Fissure  of  the  anus 

10.  Hemorrhoids 

11.  Prolapse  of  the  rectum 

IV.  NEW  GROWTHS 
V.  NERVOUS  DISTURBANCES 

1.  Nervous  vomiting 

2.  Nervous  diarrhea 

VI.  DISTURBANCES  OF  DIGESTION  (FUNCTIONAL  DIS- 
TURBANCE FROM  MULTIPLE  CAUSES) 

1.  Indigestion  from  excess  of  food  as  a  whole 

2.  Indigestion  from  excess  of  the  various  food  elements 

a.  Fat 

b.  Carbohydrate 


350  Diseases  of  the  Gastro-Enteric  Tract 

c.  Protein 

d.  Mineral  salts 

3.  Indigestion  with  fermentation 

VII.  INFECTIONS 

1.  Infectious  diarrhea 

a.  Dysentery  bacillus 

b.  Gas  bacillus 

c.  Other  organisms 

2.  Cholera  infantum 

3.  Gastritis 

4.  Proctitis 

5.  Appendicitis 

VIII.  UNCLASSIFIED 

1.  Constipation 

2.  Incontinence  of  feces 

3.  Peptic  ulcer 

4.  Intestinal  worms 


/ 


u 


fe 


I.     MALFORMATIONS 

Developmental  malformations  of  the  stomach  and  intestines  are 
comparatively  rare.  A  malposition  of  the  stomach  may  be  met  with 
in  various  places,  one  of  which  is  in  the  thoracic  cavity.  They  are 
very  rare  and  are  of  anatomical  rather  than  of  clinical  interest,  as 
the  diagnosis  can  scarcely  be  made  during  hfe.  Malformations  of 
the  stomach  are  represented  by  a  narrowing  of  either  the  cardiac 
or  pyloric  orifice  of  the  stomach  or  by  a  constriction  in  various  parts 
of  the  ventral  cavity  (hour-glass  contractions). 

MALFORMATIONS  OF  THE  RECTUM.— From  the  cHnical 
point  of  view,  malformations  of  the  rectum  are  the  most  important 
developmental  lesions  of  the  gastro-enteric  tract.  This  lesion  is 
usually  spoken  of  as  imperforate  anus,  but  several  different  condi- 
tions may  be  present.  In  one  variety  the  intestine  is  normal  to  the 
lowest  extremity  of  the  rectum,  but  there  is  a  persistent  cutaneous 
septum  closing  the  opening.  This  form  is  very  easily  curable  by 
surgical  operation. 

In  the  second  form,  the  anus  and  the  lower  part  of  the  rectum 
are  normal,  but  a  short  distance  up  there  is  a  membrane  separating 
the  lower  part  of  the  rectum  from  the  upper.  This  condition  can 
be  recognized  by  inserting  the  finger  in  the  anus,  when  the  bulging 
of  the  distended  rectum  can  easily  be  felt.  This  form  also  is  easily 
cured  by  surgery. 

In  a  third  form  the  rectum  terminates  in  a  blind  pouch  at  a 
variable  distance  from  the  anus,  the  lower  part  being  represented 
only  by  a  fibrous  cord.  This  condition  can  only  be  remedied  by 
surgical  operation,  and  is  much  more  serious. 

There  may  also  be  stenosis  of  the  rectum,  without  complete  occlu- 
sion, giving  rise  to  symptoms  of  stricture.  Some  of  these  cases  are 
curable  by  dilatation. 

MALFORMATIONS  OF  THE   SMALL  INTESTINE.— These, 

while  not  very  common,  present  a  great  variety  of  lesions.  The 
lesion  may  be  either  atresia  or  stenosis,  and  may  be  situated  at  any 
single  point,  or  may  be  multiple,  situated  at  many  points.  The 
lesions  are  most  often  situated  in  the  upper  part  of  the  small  intes- 
tine. Atresia  is  rather  more  common  than  stenosis.  The  lumen 
of  the  intestine  may  be  obliterated  at  a  circumscribed  point,  or  for 
a  considerable  distance,  the  obliterated  portion  being  represented  by 
a   fibrous   cord.     The   intestine   above   the   point  of  obstruction  is 


352  Diseases  of  the  Gastro-Enteric  Tract 

always  found  much  distended,  while  the  intestine  below  is  collapsed, 
and  usually  somewhat  atrophied. 

The  symptoms  of  these  malformations  appear  soon  after  birth, 
and  are  those  of  intestinal  obstruction.  In  atresia,  fecal  movements 
are  not  passed,  and  the  duration  of  Hfe  is  rarely  more  than  a  week, 
being  shorter,  the  higher  the  obstruction.  In  stenosis,  the  patient 
may  live  for  several  months. 

The  diagnosis  is  comparatively  easy,  as  in  a  case  of  marked  intes- 
tinal obstruction  in  a  newborn  baby  showing  nothing  abnormal  about 
the  anus,  malformation  of  the  intestine  is  the  only  probable  cause. 
The  nature  of  the  obstruction,  whether  stenosis  or  atresia,  and  its 
situation,  can  be  recognized  by  taking  a  roentgenogram  after  a 
bismuth  meal.  The  condition  is  usually  beyond  the  range  of  surgi- 
cal interference. 

Meckel's  Diverticulum. — This  is  the  remains  of  the  omphalo- 
mesenteric duct.  Usually  it  exists  as  a  blind  pouch  given  off  from 
the  ileum  about  a  foot  above  the  ileo-caecal  valve,  having  a  length 
up  to  two  or  three  inches,  and  communicating  with  the  intestine. 
In  this  form,  it  causes  no  clinical  symptoms.  In  some  cases  the 
extremity  of  the  pouch  may  continue  into  a  fibrous  cord,  which  may 
be  free  in  the  abdominal  cavity,  or  may  be  attached  to  the  umbilicus. 
In  the  latter  case,  it  may  compress  a  coil  of  intestine,  leading  to 
obstruction  or  strangulation.  This  may  occur  either  in  infancy  or 
in  later  hfe.  The  tumor  at  the  umbilicus  caused  by  Meckel's  Diverti- 
culum when  it  remains  pervious,  has  been  described  under  Diseases 
of  the  Newborn. 

Malpositions  of  the  intestine  are  met  with  in  infants  when  there 
is  a  transposition  of  the  abdominal  organs,  or  when  portions  of  the 
intestine  are  found  involved  in  other  gross  malformations,  in  which 
they  may  be  entirely  outside  the  abdominal  cavity. 


II.     TRAUMATIC  MECHANICAL  INJURIES 

FOREIGN  BODIES 

It  is  common  for  young  children,  especially  those  between  the  ages 
of  one  and  four  years,  to  swallow  various  objects.  There  is  the  very 
greatest  variety  in  the  articles  thus  swallowed,  including  everything 
that  the  young  child  can  reach  and  put  into  its  mouth.  The  most 
common  articles  swallowed  are  buttons,  coins,  pins,  pebbles,  marbles, 
and  detached  parts  of  toys.  Sharp  articles  as  well  as  smooth  ones 
may  be  swallowed.  Sometimes  the  articles  swallowed  lodge  in  the 
pharynx  or  esophagus,  but  in  the  majority  of  cases  they  pass  into 
the  stomach,  and  on  through  the  intestinal  canal.  Foreign  bodies 
usually  cause  very  slight  if  any  injury  to  the  gastro-enteric  tract. 
Sharp  bodies  may  cause  slight  hemorrhage  in  the  throat  at  the  time 
of  swallowing,  and  from  the  rectum  at  the  time  of  passage.  Impac- 
tion and  perforation,  while  possible,  are  exceedingly  rare. 

SYMPTOMS. — In  the  majority  of  cases,  even  with  sharp  and 
angular  as  well  as  smooth  bodies,  there  are  no  symptoms  whatever. 
Occasionally,  at  the  time  of  swallowing  there  may  be  an  attack  of 
choking  and  pharyngeal  pain,  and  with  sharp  bodies  there  may  be 
pain  as  well  as  hemorrhage  at  the  time  of  passage  past  the  sphincter 
ani.  While  the  body  is  passing  through  the  intestine,  there  may  be 
some  colicky  pain.  The  time  required  for  a  foreign  body  to  traverse 
the  gastro-intestinal  tract  is  usually  from  three  to  ten  days. 

DIAGNOSIS. — Owing  to  the  absence  of  symptoms,  the  diagnosis 
cannot  be  made  on  any  basis  other  than  the  story  of  the  parent, 
which  may  be  reliable,  but  which  also  may  be  a  false  alarm.  The 
diagnosis  can  only  be  made  positively  by  X-ray  examination,  which 
should  be  made  in  every  case,  if  possible. 

PROGNOSIS. — Parents  should  be  reassured,  and  told  that  only 
in  the  most  exceptional  cases  is  the  swallowing  of  a  foreign  body  a 
cause  of  harm.  Even  a  sharp,  open  safetypin  will  usually  go  through 
without  symptoms. 

TREATMENT. — The  diet  should  contain  an  abundance  of  those 
articles  of  food  which  leave  a  large  residue,  such  as  coarse  cereals, 
bread,  and  green  vegetables.  The  stools  should  be  carefully  watched 
for  the  passage  of  the  foreign  body.  No  emetics  or  cathartics  should 
ever  be  given.  Surgical  interference  should  never  be  considered, 
unless  definite  localizing  symptoms  have  developed. 
23 


354  Diseases  of  the  Gastro-Enteric  Tract 

'*  HAIR  BALL  "  IN  THE  STOMACH 

This  condition  is  also  caused  by  the  swallowing  of  foreign  bodies, 
but  is  clinically  quite  distinct  from  the  condition  described  above. 
It  is  caused  by  a  habit  sometimes  seen,  especially  in  nervous  or 
excitable  children,  of  pulling  off  and  swallowing  such  substances  as 
hair,  wool,  fur,  or  shreds  of  clothing.  The  commonest  substance  is 
hair  from  the  patient's  own  head. 

These  substances  may  be  vomited  or  may  pass  through  the  gastro- 
enteric tract,  and  be  passed  from  the  bowel  like  other  foreign  bodies, 
and  this  is  what  usually  occurs  in  infants,  with  whom  the  quantity 
swallowed  is  usually  small.  In  older  children,  the  hair,  or  similar 
substance,  may  accumulate,  forming  a  ball,  most  often  in  the  stom- 
ach, but  rarely  in  the  intestine.  The  condition  is  most  often  seen 
in  girls,  on  account  of  their  long  hair.  The  habit  may  continue 
imtil  quite  large  tumors  have  been  formed,  which  may  even  attain 
a  weight  of  several  pounds. 

SYMPTOMS.— Usually  the  first  thing  noted  by  the  parents  in 
these  cases  is  the  tumor.  Sometimes  there  is  vague  gastric  dis- 
turbance.    Epigastric  pain  is  more  common  than  vomiting. 

DIAGNOSIS. — The  diagnosis  is  not  often  made  until  operation 
is  performed.  The  tumors  have  been  mistaken  for  cancer,  a  dis- 
placed spleen  or  kidney,  impacted  feces,  and  tuberculosis  of  the 
mesenteric  lymphnodes. 

TREATMENT. — The  mass  must  be  removed  by  operation  in 
most  cases.  There  are  a  few  recorded  instances  of  disappearance 
of  the  tumor  and  subsequent  passage  of  the  ball,  after  catharsis. 
The  outcome  after  operation  is  favorable. 

CORROSIVE  GASTRITIS 

The  lesions  in  this  condition  are  caused  by  the  swallowing  of 
strong  irritants.  The  most  common  are  carbolic  acid,  and  the 
caustic  alkalies. 

PATHOLOGICAL  ANATOMY.— \\Tien  strong  caustics  are  swal- 
lowed, the  most  extensive  lesions  are  usually  found  in  the  pharynx 
and  esophagus,  the  muscular  spasm  of  these  parts  usually  preventing 
all  but  a  small  quantity  of  the  caustic  from  reaching  the  stomach. 
In  the  stomach  the  lesions  are  usually  found  on  the  summits  of  the 
rugae.  Their  character  varies  from  slight  superficial  necrosis  of  the 
mucous  membrane,  to  deep  ulceration,  or  even  perforation,  the 
variations  depending  on  the  amount  and  concentration  of  the  caustic, 
and  whether  the  stomach  was  full  or  empty  at  the  time  of  swallow- 
ing.    There  is  usually  marked  congestion  of  the  mucous  membrane 


Corrosive  Gastritis  355 

about  the  ulcers,  and  often  considerable  extravasation  of  blood.  If 
death  does  not  occur  very  speedily,  evidences  of  intense  inflammation 
are  found. 

SYMPTOMS. — The  chief  symptoms  are  pain  and  a  sense  of  con- 
striction, and  vomiting,  which  takes  place  almost  immediately.  The 
vomitus  usually  contains  blood.  Examination  of  the  mouth  and 
throat  usually  shows  greyish  or  whitish  lesions  on  the  mucous  mem- 
brane. When  the  lesions  in  the  stomach  are  severe,  collapse  develops 
rapidly,  and  death  occurs  from  shock.  In  milder  cases  there  is 
continued  pain  and  vomiting,  with  epigastric  tenderness,  and  there 
may  be  diarrhea  with  bloody  mucous  stools.  In  infants,  death 
usually  occurs  within  a  few  days,  even  in  the  milder  cases.  In  older 
children,  recovery  may  occur,  to  be  later  followed  often  by  cicatricial 
contraction  and  deformity  of  the  stomach. 

TREATMENT. — The  first  indication  in  treatment  is  to  admin- 
ister the  proper  chemical  antidote  for  the  substance  swallowed. 
Washing  out  the  stomach  with  the  tube  should  be  avoided.  Sooth- 
ing- mucilaginous  or  oily  fluids  should  be  given,  such  as  olive  oil. 
Later,  milk  or  albumin  water  should  be  given. 


III.     MECHANICAL  CONDITIONS  OF  INTERNAL 

ORIGIN 

HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS 

This  is  a  condition  characterized  by  hypertrophy  of  the  circular 
muscular  fibres  of  the  pylorus.  It  is  probably  always  congenital  in 
origin,  although  it  is  likely  that  the  amount  of  muscular  hypertrophy 
may  increase  after  birth.  The  congenital  nature  of  the  disease 
might  suggest  its  classification  under  the  malformations,  but  it  is 
not  a  condition  resembling  the  malformations  which  can  be  traced 
to  definite  anomahes  of  fetal  development,  and  its  results  are  of  a 
purely  mechanical  nature. 

ETIOLOGY. — The  etiology  of  pyloric  stenosis  is  unknown.  Two 
theories  have  been  advanced:  first,  that  the  hypertrophy  is  the 
result  of  muscular  spasm,  and  second,  that  it  is  a  developmental 
abnormahty.  The  first  theory  assumes  that  in  those  cases  in  which 
the  symptoms  appear  very  soon  after  birth,  the  muscular  spasm 
occured  during  intra-uterine  hfe.  The  chief  evidence  in  favor  of 
the  first  theory  is  the  late  development  of  the  S3miptoms  seen  in 
some  cases.  That  muscular  spasm  during  fetal  Hfe  is  the  cause  is 
improbable,  and  the  late  development  of  symptoms  sometimes  seen 
may  be  explained  on  the  ground  that  when  the  stenosis  is  partial, 
it  may  not  be  sufficient  to  cause  symptoms  unless  complicated  by 
spasm,  which  may  develop  late  as  the  result  of  indigestion.  The 
frequent  occurrence  of  very  marked  cases  in  newborn  babies  is 
strongly  in  favor  of  the  second  theory,  and  the  weight  of  opinion 
regards  pyloric  spasm  as  a  congenital  anomaly. 

Pyloric  stenosis  occurs  more  frequently  in  boys  than  in  girls,  and 
is  fully  as  common  in  breast-fed  babies  as  in  the  artificially  fed. 

PATHOLOGICAL  ANATOMY.— The  disease  has  a  definite  path- 
ological anatomy,  on  which  alone  its  certain  diagnosis  can  rest.  The 
h^-pertrophy  is  chiefly  in  the  circular  layer  of  muscle  fibres  at  the 
pylorus,  which  layer  is  usually  two  or  three  times  its  normal  thick- 
ness. This  thickening  is  due  to  an  increased  number  of  fibres,  rather 
than  to  the  presence  of  fibres  of  increased  size.  The  layer  of  longi- 
tudinal fibres  is  usually  of  normal  thickness.  The  mucosa  is  some- 
what thickened,  particularly  in  its  longitudinal  folds,  and  the  sub- 
mucosa  may  be  sHghtly  thickened. 

Macroscopically,  in  marked  cases,  the  lesion  appears  as  a  hard, 
whitish  tumor  at  the  pylorus,  resembling  an  oHve  in  size  and  shape. 


Pyloric  Stenosis  357 

In  milder  cases,  there  may  be  thdckening  about  the  pylorus,  with- 
out a  definite  tumor. 

There  is  great  variation  in  the  effect  of  the  hypertrophy  on  the 
lumen  of  the  pylorus.  In  some  cases  the  pyloric  orifice  is  completely 
occluded  at  birth,  no  gastric  contents  being  permitted  to  pass  into 
the  duodenum.  In  other  cases,  representing  the  most  common 
type,  complete  occlusion  is  not  present  at  birth,  but  develops  in  the 
course  of  a  few  weeks.  In  still  less  marked  cases,  the  narrowing  of 
the  lumen  is  less  extreme,  and  complete  occlusion  never  occurs. 
Slight  narrowing  may  possibly  be  compensated  by  the  growth  of  the 
pylorus  with  age,  or  may  at  any  time  later  give  rise  to  symptoms. 
Autopsies  on  infants  previously  operated  on  for  pyloric  stenosis,  have 
shown  no  tendency  toward  diminution  of  the  hypertrophy. 

There  is  usually  some  hypertrophy  of  the  muscles  of  the  walls  of 
the  stomach,  especially  in  the  region  of  the  pylorus.  There  is  almost 
always  some  dilatation  of  the  stomach,  which  may  become  very 
marked,  especially  in  cases  of  incomplete  occlusion,  in  which  there  is 
a  long  duration  of  the  obstruction.  There  is  sometimes  some  dila- 
tation of  the  oesaphagus.     There  are  no  inflammatory  lesions. 

SYMPTOMS. — The  characteristic  symptoms  of  h3rpertrophic  steno- 
sis of  the  pylorus  are  vomiting,  constipation,  and  loss  of  weight. 

Vomiting  is  the  first  symptom  noted.  It  may  begin  in  the  earliest 
days  of  life,  but  usually  does  not  appear  until  the  beginning  of  the 
second  week.  It  may  not  appear  until  still  later,  but  rarely  fails 
to  develop  before  the  end  of  the  first  month.  In  the  beginning 
there  is  nothing  to  distinguish  the  vomiting  from  that  seen  in  indi- 
gestion, but  in  typical  cases  it  soon  becomes  forcible  and  explosive, 
and  the  gastric  contents  may  be  shot  out  of  the  mouth  to  a  distance 
of  several  feet.  The  vomiting  usually  occurs  soon  after  the  taking 
of  food,  but  in  some  cases  it  may  not  occur  until  toward  the  end 
of  the  interval  between  feedings.  In  many  cases,  the  vomiting  is 
seen  after  every  feeding,  but  sometimes  several  feedings  may  be 
retained,  and  later  expelled  together.  The  vomiting  does  not  appear 
to  be  accompanied  by  pain,  but  often  there  are  evidences  of  dis- 
comfort, as  shown  by  the  baby's  squirming  and  drawing  up  its  knees, 
in  the  interval  between  the  feeding  and  its  expulsion.  The  vomitus 
at  first  consists  only  of  the  food  taken,  more  or  less  digested  accord- 
ing to  the  time  after  feeding;  later  it  may  contain  mucus,  but  does 
not  contain  bile,  except  in  the  rarest  cases.  The  babies  are  hungry, 
take  their  food  readily,  and  are  willing  to  try  it  again  right  after 
vomiting.  The  vomiting  is  not  often  permanently  influenced  by 
changes  in  the  composition  of  the  food,  but  quite  often  changes  in 
the  milk  modification  given  are  followed  by  an  improvement  in  the 
vomiting  which  proves  to  be  only  temporary.     This  feature  is  often 


358  Diseases  op  the  Gastro-Enteric  Tract 

misleading  as  to  the  diagnosis,  the  temporary  responses  to  dietetic 
treatment  leading  the  physician  to  believe  that  the  vomiting  is 
caused  by  indigestion.  In  some  cases  of  partial  occlusion,  in  which 
the  symptoms  develop  late,  and  are  complicated  by  spasm,  there  is 
a  more  permanent  response  to  changes  in  the  composition  of  the 
food,  the  babies  doing  better  on  one  food  than  on  another,  and  this 
tends  still  more  to  obscure  the  diagnosis. 

Constipation  appears  early  in  pyloric  stenosis.  In  severe  cases, 
with  complete  occlusion  of  the  pyloric  orifice,  the  stools  contain  no 
normal  fecal  material,  and  resemble  meconium  in  appearance.  In 
milder  cases,  with  only  partial  obstruction,  the  stools  contain  fecal 
matter,  and  are  not  notably  abnormal  in  appearance,  although  very 
small  in  size. 

Loss  of  weight  is  an  important  symptom.  In  cases  with  com- 
plete or  marked  obstruction,  loss  of  weight  is  constant  and  pro- 
gressive, becoming  more  rapid  as  time  goes  on.  Eventually  the 
baby  shows  all  the  signs  of  starvation,  with  marked  emaciation, 
pinched  face,  and  dry  skin.  In  cases  with  partial  obstruction,  loss 
of  weight  occurs  eventually,  but  there  may  be  long  periods  during 
which  with  careful  feeding,  the  weight  curve  remains  stationary,  or 
shows  only  very  gradual  decline.  The  diagnosis  is  made  more  diffi- 
cult in  cases  of  partial  obstruction  by  this  feature. 

Physical  Examination. — The  important  points  on  physical  ex- 
amination are:  i,  visible  peristalsis,  2,  palpable  tumor,  and  3,  delayed 
emptying  time  of  the  stomach. 

Early  in  the  course  of  the  disease,  when  vomiting  has  recently 
begun,  inspection  of  the  abdomen  usually  shows  nothing  abnormal. 
Later,  prominence  or  ballooning  of  the  epigastrium,  and  peristaltic 
waves  running  from  left  to  right,  are  seen  when  the  stomach  is  full. 
In  examining  a  case  of  suspected  pyloric  stenosis,  the  physician 
should  have  a  feeding  given.  Immediately  after  the  feeding,  the 
abdomen  should  be  bared,  and  the  physician  should  watch  the  epi- 
gastrium. Prominences  are  formed,  about  half  the  size  of  an  egg, 
which  successively  run  slowly  across  the  epigastrium  from  left  to 
right,  and  disappear.  If  this  visible  peristalsis  does  not  appear,  the 
physician  should  try  stroking  the  epigastrium  with  the  fingers,  or 
applying  a  towel  wet  in  cold  water,  or  a  piece  of  ice.  These  meas- 
ures will  usually  elicit  the  phenomenon  when  it  is  present.  Some- 
times dilatation  of  the  stomach  may  be  made  out  from  the  size  of 
the  area  involved  in  the  visible  peristalsis. 

A  tumor  may  be  felt  in  most  cases  with  marked  or  complete  ob- 
struction, and  in  some  cases  with  partial  obstruction.  The  situation 
of  the  tumor  is  not  constant,  but  its  most  common  situation  is  a 
little  to  the  right  of  the  median  Hne,  and  about  midway  between 


lU 


Fig.  82 — Pyloric  stenosis  with  complete  occlusion 
RoentKeno";ram  taken  four  hours  after  bismuth  meal 


Pyloric  Stenosis  359 

the  tip  of  the  ensiform  cartilage  and  the  umbilicus.  At  times  it 
is  high  up  under  the  edge  of  the  liver,  or  low  down  near  the  level 
of  the  navel.  If  visible  peristaltic  waves  are  present,  the  tumor 
may  often  be  found  where  they  disappear.  The  tumor  feels  hard, 
and  is  about  the  size  of  the  tip  of  the  thumb,  or  of  an  olive.  Id 
examining  for  tumor,  the  physician  should  palpate  first  when  the 
stomach  is  empty  before  the  feeding  is  given ;  again  when  the  stomach 
is  full  while  watching  for  visible  peristalsis,  and  again  during  the 
relaxation  which  occurs  after  vomiting.  The  tumor  may  be  best 
felt  at  any  of  these  times,  but  is  most  often  best  felt  immediately 
after  vomiting.  If  there  are  other  strong  evidences  of  pyloric  sten- 
osis, but  no  tumor  felt,  an  examination  should  be  made  with  the 
baby  under  an  anesthetic.  In  pyloric  stenosis  the  tumor  never 
varies  in  size. 

Delayed  emptying  time  of  the  stomach  may  be  recognized  by 
two  methods  of  examination: — i,  by  roentgenograms  of  the  stomach 
taken  after  a  meal  containing  bismuth;  2,  by  aspiration  of  the  stom- 
ach contents  with  a  stomach-tube  at  various  periods  after  feeding. 

In  routine  practice,  it  is  best  to  take  three  roentgenograms,  the 
first,  immediately  after  the  giving  of  the  bismuth  meal,  the  second 
at  the  expiration  of  two  hours,  and  the  third  at  the  expiration  of 
four  hours.  In  normal  cases,  with  a  dilute  milk  given  as  the  basis 
of  the  bismuth  meal,  the  first  plate  should  show  that  the  passage  of 
some  food  through  the  pylorus  into  the  duodenum  has  already  taken 
place.  The  second  plate,  taken  after  two  hours,  should  show  either 
an  empty  stomach,  or  very  little  bismuth  in  the  stomach,  most  of 
the  meal  being  in  the  intestine.  The  third  plate,  taken  after  four 
hours,  should  show  the  stomach  empty.  In  cases  of  hypertrophic 
stenosis  with  complete  occlusion  of  the  pylorus,  the  test  meal  remains 
in  the  stomach  until  it  is  vomited,  and  none  of  the  plates  shows  any 
passage  of  bismuth  into  the  intestine.  In  cases  of  partial  obstruc- 
tion, the  first  plate  shows  the  passage  of  very  little  or  no  bismuth 
into  the  duodenum,  the  second  plate  shows  the  passage  of  a  little, 
most  of  the  meal  remaining  in  the  stomach,  while  the  third  plate 
still  shows  part  of  the  meal  in  the  stomach.  The  advantage  of  this 
method  of  investigation  is  that  it  gives  positive  evidence  as  to  whether 
the  pyloric  obstruction  is  complete  or  partial,  and  gives  a  permanent 
record  of  the  delay  in  the  emptying  time.  Its  disadvantage  is  that 
sometimes  the  bismuth  in  the  meal  causes  a  shght  delay  in  the  empty- 
ing time  in  cases  in  which  conditions  at  the  pylorus  are  normal. 

To  measure  the  emptying  time  with  the  stomach  tube,  an  appa- 
ratus should  be  employed  similar  to  that  shown  in  the  illustration. 
This  consists  of  a  soft  rubber  catheter,  size  21  F.,  a  glass  bulb  with 
two  glass  prolongations  at  opposite  sides  to  serve  as  nozzles,  and 
a  funnel  attached  to  a  rubber  tube.     At  the  end  of  two  or  four  hours 


360 


Diseases  of  the  Gastro-Enteric  Tract 


after  a  feeding,  the  catheter  is  passed  into  the  stomach,  the  nozzle 
of  the  bulb  is  inserted  into  the  catheter,  and  the  physician  sucks 
through  the  other  nozzle  of  the  bulb.  If  curds  in  the  stomach  ob- 
struct the  end  of  the  catheter,  the  physician  attaches  the  rubber 
tube  to  the  nozzle  of  the  bulb,  and  pours  in  water  through  the  funnel, 
then  lowering  the  funnel  and  withdrawing  the  gastric  contents  by 
siphonage.  When  siphonage  ceases,  aspiration  should  be  tried 
again.     All  water  used  should  be  taken  from  a  measured  amount  in 

Fig.  87 


Apparatus  for  estimating  gastric  retention  time 


a  graduate,  and  all  fluid  obtained  from  the  stomach  should  be  put 
into  this  graduate,  which  will  then  show,  as  an  excess  over  the  original 
quantity  contained  in  the  graduate,  the  quantity  obtained  from  the 
stomach.  Little  or  no  residue  should  normally  be  obtained  after 
two  hours,  and  none  after  four  hours.  This  method  has  the  advan- 
tage of  avoiding  the  delay  in  the  emptying  time  sometimes  caused 
by  bismuth,  and  it  sometimes  shows  the  retention  of  several  feedings 
and  dilatation  of  the  stomach.  It  does  not,  however,  throw  definite 
light  on  whether  the  obstruction  is  complete  or  partial. 

DIAGNOSIS. — In  well-marked  cases  of  hypertrophic  stenosis  of 
the  pylorus,  with  complete  occlusion  of  the  pyloric  orifice,  the  diag- 
nosis is  very  easy.     In  marked  cases,  the  symptoms  usually  begin 


Fig.  83 — Pyloric  stenosis  wilii  [):irti;il  occlusion 
Roentgenogram  taken  immediately  after  bismuth  meal  and  showing  a  very  little  bismuth 

in  the  intestine 


Fig.  84 — Pyloric  stenosis  with  partial  occlusion 

RoentRcnogram  of  the  same  case  taken  four  hours  after  bismuth  meal,  showing  passage  of 

the  food  into  the  intestine,  and  retention  of  a  portion  in  the  stomach. 


Pyloric  Stenosis 


361 


within  a  few  days  or  weeks  after  birth,  and  vomiting  beginning  at 
this  period  of  Hfe,  having  no  relation  to  the  composition  of  the  food, 
or  occurring  in  breast-fed  babies,  should  always  arouse  in  the  physi- 
cian's mind  the  suspicion  of  pyloric  stenosis.  The  projectile  char- 
acter of  the  vomiting,  the  marked  constipation  with  meconium-like 
stools,  the  visible  gastric  peristalsis,  and  the  palpable  tumor,  all 
make  up  an  unmistakable  picture.  In  these  pronounced  cases  the 
tumor  can  usually  be  found,  if  carefully  sought,  but  not  always. 
The  finding  of  the  tumor  is  not  necessary  in  these  cases  for  the  mak- 
ing of  a  positive  diagnosis,  but  when  a  tumor  is  not  found,  the  diag- 
nosis should  always,  if  possible,  be  confirmed  by  a  roentgenogram 
taken  after  a  bismuth  meal. 

Fig.  88 


Aspiration  of  the  gastric  contents.     Apparatus  used  in  estimating  gastric 
capacity  and  retention  time 


In  cases  in  which  the  clinical  picture  is  less  pronounced,  repre- 
senting usually  a  condition  in  which  the  muscular  h\T)ertrophy  at 
the  pylorus  causes  only  a  partial  stenosis,  but  not  a  complete  occlu- 
sion of  the  pyloric  opening,  the  diagnosis  is  often  more  difficult. 
In  such  cases  the  condition  must  be  differentiated  from  muscular 
spasm  of  the  pylorus,  from  indigestion,  and  from  habitual  vomiting. 

Spasm   of   the   Pylorus. — The   diagnosis   between   hypertrophic 


362  Diseases  of  the  Gastro-Enteric  Tract 

stenosis  of  the  pylorus  with  partial  obstruction,  and  pyloric  spasm 
is  often  extremely  difficult.  The  distinction  between  these  two 
conditions  has  not  always  been  well  maintained  in  the  literature 
of  the  subject,  nor  by  some  surgeons,  who  have  classified  as  h5^er- 
trophic  stenosis  only  those  cases  in  which  a  tumor  was  found,  or  in 
which  the  obstruction  was  complete.  The  only  truly  scientific 
distinction  is  based  on  pathological  anatomy,  spasm  of  the  pylorus 
showing  no  abnormal  condition  of  the  tissues  at  the  pylorus.  Every 
case  in  which  there  is  any  hypertrophy  of  the  circular  muscular 
layer,  should  be  classified  as  hypertrophic  stenosis,  whether  or  not 
there  be  a  palpable  or  visible  tumor,  and  whether  or  not  the  obstruc- 
tion be  complete. 

Both  conditions,  stenosis  and  spasm,  may  show  the  same  mode 
of  onset.  Vomiting  may  be  explosive  in  both;  it  may  be  tem- 
porarily relieved  by  dietetic  treatment  in  partial  stenosis,  while  in 
spasm  it  may  at  times  be  resistant  to  dietetic  treatment.  The 
symptoms  of  constipation,  loss  of  weight,  visible  peristalsis,  and 
delayed  emptying  time  of  the  stomach  are  common  to  both  con- 
ditions. There  is  occasionally,  though  not  often,  a  palpable  tumor 
in  spasm,  while  in  mild  cases  of  stenosis  a  tumor  is  often  not  found. 
Nevertheless,  the  differentiation  of  the  two  conditions  is  essential 
in  prognosis  and  treatment. 

The  presence  of  a  typical  palpable  tumor  is  strongly  in  favor  of 
hypertrophic  stenosis,  and  is  usually  conclusive  proof  of  the  diag- 
nosis. Tumor  is  occasionally  present  in  spasm,  but  the  tumor  of 
spasm  is  smaller  and  cord-like  in  feel,  and  is  apt  to  vary  in  size  during 
the  examination.  The  absence  of  a  palpable  tumor  after  careful  and 
repeated  examination,  is  evidence  against  stenosis,  but  does  not 
exclude  it. 

The  following  points  are  evidence  only  in  differential  diagnosis, 
and  none  of  them  is  positively  diagnostic.  Marked  and  persistent 
constipation  points  toward  stenosis,  although  in  mild  cases  of  ste- 
nosis with  partial  obstruction,  constipation  may  not  be  more  marked 
than  in  spasm.  If  the  baby  is  breast-fed,  it  points  toward  stenosis, 
because  pyloric  spasm  is  very  uncommon  in  breast-fed  babies.  When 
the  symptoms  develop  soon  after  birth,  especially  in  babies  who  are 
properly  fed,  it  is  in  favor  of  hypertrophic  stenosis.  Rapid  and 
permanent  improvement  in  the  symptoms,  under  regulation  of  the 
diet  with  carefully  modified  milk,  or  with  any  of  the  particular 
resources  of  infant  feeding,  is  in  favor  of  spasm,  while  resistance  to 
proper  treatment  is  in  favor  of  stenosis.  This  evidence  is  by  no  means 
positive,  as  cases  of  hypertrophic  stenosis  are  often  complicated  by 
spasm,  and  respond  to  a  certain  extent  to  dietetic  treatment,  while 
some  cases  of  spasm  are  resistant.  Roentgenograms  after  a  bismuth 
meal  do  not  help  in  the  differential  diagnosis,  as  in  both  spasm  and 


Fig.  85 — Pyloric  stenosis  with  pailial  occlusion 
Roentgenogram  taken  two  hours  after  Insmuth  nicil,  showing  dilatation  of  the  stomach. 


Fig.  86 — Pyloric  stenosis  with  partial  occlusion 
Same  case  taken  four  hours  after  bismuth  meal 


Pyloric  Stenosis  363 

stenosis  with  partial  obstruction, ,  there  is  delayed  emptying-time. 
At  times  the  investigation  of  the  emptying-time  by  X-ray,  or  by  the 
stomach  tube,  reveals  evidence  of  dilatation  of  the  stomach.  This 
is  strongly  in  favor  of  h^'pertrophic  stenosis  as  dilatation  is  very 
rarely  seen  in  spasm.  The  absence  of  evidence  of  dilatation  is  not 
against  stenosis,  and  throws  no  light  on  the  diagnosis. 

In  spite  of  these  various  forms  of  evidence,  the  differential  diag- 
nosis between  a  slight  or  moderate  degree  of  hypertrophic  stenosis, 
possibly  complicated  by  spasm,  and  spasm,  without  organic  tissue- 
change,  remains  extremely  difficult  in  many  cases.  The  symptoms, 
and  evidence  are  often  very  confusing,  and  have  led  to  an  effort 
to  find  a  more  exact  method  of  investigation. 

Diagnosis  by  Duodenal  Catheter. — I  have  recently  adopted  the  pas- 
sage of  the  duodenal  catheter,  as  recommended  by  Hess,  as  a  means 
of  investigation  in  obstructive  conditions  of  the  pylorus,  and  believe 
it  to  give  most  valuable  evidence  in  the  differential  diagnosis  of 
h}^ertrophic  stenosis  and  spasm.  In  Hess's  method,  a  long  and- 
very  flexible  catheter  was  used,  which  was  introduced  with  a  meal, 
the  end  of  the  catheter  being  eventually  carried  through  with  the 
food  into  the  duodenum.  The  advantage  of  such  a  tube  is  that  it 
is  usually  carried  sufiiciently  far  into  the  duodenum  to  permit  the 
flow  of  bile,  which  is  certain  proof  of  its  passage  through  the  pylorus. 
The  disadvantage  of  such  a  catheter  is  that  it  often  requires  consider- 
able time  to  enter  the  duodenum,  and  does  not  permit  so  accurate 
an  estimate  of  the  size  of  the  pyloric  orifice  as  does  a  somewhat 
stifi'er  tube,  which  enters  the  duodenum  impelled  by  the  pushing 
of  the  operator. 

We  have  been  using  at  the  Infant's  Hospital  ordinary  soft  rubber 
urethral  catheters  of  graded  sizes,  these  tubes  being  quite  long  enough 
to  enter  the  duodenum,  though  not  long  enough  always  to  obtain 
bile.  Repeated  controls  made  by  filling  the  tubes  with  bismuth, 
and  taking  a  roentgenogram  after  passing  the  catheter,  have  shown 
that  in  normal  cases,  or  in  cases  of  pyloric  spasm,  these  tubes  speedily 
enter  the  duodenum,  and  these  controls  have  convinced  us  that  it 
is  quite  easy  to  recognize  the  moment  when  the  catheter  passes 
the  pylorus. 

The  catheter  is  passed  as  is  the  ordinary  stomach  tube,  but  more 
slowly,  the  physician  watching  carefully  for  the  various  reflexes 
which  mark  its  progress.  When  the  end  of  the  tube  passes  along 
the  throat,  the  pharyngeal  reflex  is  shown  by  the  gagging  and  cough- 
ing of  the  baby.  While  the  tube  is  passing  through  the  esophagus, 
the  baby  is  comparatively  quiet,  but  a  second  gagging  reflex  is  ob- 
served, and  a  slight  sense  of  resistance  is  felt,  when  the  tube  passes 
the  cardiac  orifice  of  the  stomach.  After  the  tube  enters  the  stom- 
ach, resistance  diminishes,  and  at  this  time  gastric  contents  may  be 


364  Diseases  of  the  Gastro-Enteric  Tract 

expelled,  or  may  be  aspirated,  through  the  tube,  and  if  the  catheter 
is  released  by  the  physician's  fingers  it  tends  to  come  back  at  the 
baby's  mouth.  The  catheter  is  passed  slowly  on  until  a  slight  sense 
of  resistance  is  encountered,  when  it  is  held  firmly  in  situ,  with  con- 
tinued sHght  pressure.  During  this  period,  the  baby  again  shows 
marked  evidence  of  discomfort,  squirms,  cries,  and  may  again  gag 
or  vomit.  This  is  the  pyloric  reflex.  Suddenly  the  resistance  relaxes, 
as  the  tube  passes  the  pylorus,  and  now  if  the  catheter  is  released 
by  the  physician's  fingers,  it  will  not  tend  to  come  back.  More- 
over, suction  with  the  bulb  through  the  catheter  obtains  either  no 
contents,  or  a  small  amount  of  bile.  When  the  catheter  enters  the 
duodenum,  the  baby  ceases  to  squirm  and  gag,  and  becomes  per- 
fectly comfortable.  A  gush  of  gas  from  the  catheter  also  often  marks 
the  entrance  into  the  duodenum. 

The  following  table,  based  on  the  work  of  W.  W.  Howell,  associate 
physician  at  the  Infants'  Hospital,  shows  the  various  sizes  of  catheter 
which  should  normally  pass  the  pylorus: 

Table  41 

Sizes  of  Catheter,  French  Scale,  Which  Should  Pass  the  Normal  Pylorus  at 
Various  Ages.     (Howell) 

Birth  to  2  months 13  or  14  F. 

2  to  6  months 15  or  16  F. 

.6  to  12  months 17  or  18  F. 

I  to  2  3^ears 18  to  22  F. 

In  spasm  of  the  pylorus,  there  may  be  some  delay  in  the  passage 
of  the  catheter  past  the  pylorus,  but  the  baby  will  always  take  a  cathe- 
ter of  a  size  normal  for  its  age.  In  hypertrophic  stenosis  of  the  pylorus, 
either  the  catheter  cannot  be  passed  into  the  duodenum  at  all,  or  only  a 
catheter  of  a  smaller  size  than  that  normal  for  the  age  will  pass.  Also 
the  pyloric  reflex  is  diminished  or  absent. 

The  autopsy  and  operative  findings  have,  up  to  the  present,  con- 
firmed the  accuracy  of  the  evidence  obtained  by  the  duodenal  catheter 
in  pyloric  stenosis.  The  following  table  shows  the  results  in  the 
cases  diagnosed  at  the  Infant's  Hospital  since  this  method  has  been 

in  use: 

Table  42 

Cases  Diagnosed  by  Duodenal  Catheter 

TYPE  OF  CASE        NO.  OF  CASES     TREATMENT "  MORTALITY 

Marked  obstruction 8  Prompt  operation 0% 

Partial  obstruction 3  Delaj^ed  operation 100% 

Partial  obstruction i  Dietetic  treatment 100% 

Partial  obstruction 3  Prompt  operation 0% 

Spasm 16  Dietetic  treatment 0% 

The  eight  cases  of  marked  obstruction  were  given  prompt  surgical 
treatment.  In  the  next  four  cases  of  partial  obstruction,  the  diag- 
nosis was  not  clear,  resting  only  on  the  evidence  of  the  duodenal 


Pyloric  Stenosis  365 

catheter,  and  the  surgeons  were  unwilHng  to  interfere  promptly, 
beHeving  that  they  might  be  cases  of  spasm.  All  were  fatal,  and 
in  three  in  which  necropsies  were  done,  hypertrophic  stenosis  was 
found.  In  the  other  three  cases  of  partial  obstruction,  the  evidence 
of  the  duodenal  catheter  was  accepted,  prompt  operation  was  done, 
stenosis  was  found,  and  all  recovered.  All  the  cases  in  which  the 
duodenal  catheter  excluded  hypertrophic  stenosis  recovered  without 
operation. 

Indigestion. — Marked  cases  of  pyloric  stenosis  with  their  dis- 
tinctive symptom-complex,  are  easily  distinguished  from  cases  of 
indigestion  with  vomiting.  In  every  case  in  which,  in  an  infant, 
vomiting  is  the  main  symptom,  the  possibility  of  pyloric  stenosis 
should  be  considered,  and  its  special  symptoms  should  be  sought. 
Indigestion  is  uncommon  in  breast-fed  babies,  and  never  shows 
explosive  vomiting,  visible  peristalsis,  severe  constipation,  tumor,  or 
any  marked  delay  in  the  emptying  time  of  the  stomach.  In  indiges- 
tion, roentgenograms  occasionally  show  some  retention  of  food  in 
the  stomach  for  a  longer  time  than  normal,  but  the  plate  taken 
immediately  after  the  bismuth  meal  shows  that  the  food  begins  at 
once  to  leave  the  stomach  in  normal  amounts.  The  passage  of  the 
duodenal  catheter  is  normal. 

Habitual  Vomiting. — This  is  a  condition  sometimes  seen  in 
babies,  in  which  vomiting  frequently  occurs  after  feeding  without 
other  signs  of  indigestion.  In  this  condition  there  is  no  constipa- 
tion, no  loss  of  weight,  no  visible  peristalsis,  no  palpable  tumor, 
and  no  delay  in  the  emptying  time  of  the  stomach. 

PROGNOSIS. — In  cases  of  hypertrophic  stenosis  of  the  pylorus, 
with  marked  obstruction,  or  complete  occlusion,  the  prognosis  with 
medical  treatment  is  hopeless.  Death  from  starvation  will  surely 
occur  within  a  few  weeks.  The  prognosis  in  cases  with  partial  ob- 
struction is  also  bad  under  medical  treatment.  The  babies  may 
live  for  a  considerable  time,  but  usually  die  eventually  either  from 
starvation,  or  from  some  intercurrent  affection.  There  are  many 
cases  on  record  of  recovery  under  medical  treatment  of  cases  of 
mild  pyloric  stenosis.  In  these  cases,  however,  the  diagnosis  was  not 
based  on  any  accurate  means  of  investigation,  and  all  of  them  are 
open  to  the  suspicion  of  having  been  really  cases  of  pyloric  spasm. 
There  is  no  evidence  that  organic  stenosis  tends  to  diminish,  and 
in  my  experience,  the  prognosis  with  medical  treatment  is  event- 
ually bad. 

The  prognosis  with  operation  varies  according  to  the  time  when 
the  operation  is  performed,  and  the  skill  of  the  operating  surgeon. 
The  prognosis  has  appeared  to  be  better  in  cases  of  marked  or  com- 
plete obstruction  after  operation,  than  in  cases  of  slight  obstruction. 


366  Diseases  of  the  Gastro-Enteric  Tract 

This  I  believe  to  be  due  mainly  to  the  fact  that  in  marked  cases 
the  diagnosis  is  made  with  more  certainty,  and  the  operation  per- 
formed more  promptly,  than  in  less  marked  cases.  Cases  of  partial 
obstruction  after  operation  apparently  undergo  a  more  stormy  con- 
valescence than  cases  of  complete  obstruction,  but  this  may  be  due 
to  the  fact  that  in  the  former,  symptoms  have  often  had  a  long  dura- 
tion, and  the  stomach  has  become  more  irritable. 

In  the  hands  of  a  surgeon  thoroughly  accustomed  to  operating 
upon  these  cases,  and  upon  babies,  the  prognosis  is  good,  unless 
the  operation  has  been  too  long  delayed. 

TREATMENT. — Prompt  surgical  operation  is  indicated  in  all 
severe  or  pronounced  cases  in  which  the  diagnosis  is  supported  by 
the  finding  of  a  tumor  or  by  evidence  of  complete  obstruction  as 
shown  by  X-ray.  In  cases  of  partial  obstruction  in  which  no  tumor 
can  be  made  out,  dietetic  treatment  may  be  tried,  and  if  the  baby 
responds,  it  may  be  continued  as  long  as  the  baby  is  doing  well. 
If,  however,  the  symptoms  recur,  or  the  baby  begins  to  lose  weight, 
or  does  not  begin  to  gain  after  one  or  two  weeks'  trial,  and  if  the 
diagnosis  is  supported  by  the  evidence  of  the  duodenal  catheter,  no 
further  time  should  be  wasted  with  dietetic  treatment. 

The  operation  to  be  chosen  should  depend  on  the  experience  of 
the  operating  surgeon.  Posterior  gastroenterostomy  has  been  the 
procedure  most  employed,  and  has  given  very  high  percentages  of 
recovery  in  the  hands  of  some  surgeons.  Various  forms  of  pyloro- 
plasty have  been  recommended  and  performed  by  various  surgeons, 
with  good  results.  Recently,  Dr.  James  S.  Stone  at  the  Children's 
Hospital,  has  obtained  good  results  from  simply  spHtting  the  muscle 
of  the  pyloric  ring  down  to,  but  not  through,  the  mucous  layers.  This 
operation  has  the  advantage  of  taking  much  less  time  than  the  others, 
but  has  not  yet  stood  the  test  of  time  as  has  posterior  gastroenteros- 
tomy. The  choice  of  operation  is  less  important  than  is  the  skill 
and  training  of  the  operator. 

The  operation  should  be  performed  as  soon  as  possible  after  the 
diagnosis  is  made.  Often,  however,  the  babies  are  in  very  poor 
physical  condition,  which  diminishes  the  Hkelihood  of  their  standing 
the  shock  of  so  severe  an  operation.  In  cases  of  partial  obstruc- 
tion, careful  feeding  for  a  day  or  two  may  bring  about  improvement 
in  the  general  condition,  and  I  have  found  that  if  the  duodenal 
catheter  will  pass,  the  babies  may  be  fed  through  it  with  great  ad- 
vantage, showing  marked  improvement  in  one  or  two  days.  In 
cases  of  marked  obstruction,  no  longer  delay  than  twenty-four  hours 
of  preparation  should  be  given.  During  the  period  of  preparation, 
salt  solution  should  be  given  by  rectum,  and,  if  the  general  condition 
is  poor,    also    subcutaneously.     We  have  recently  at  the  Infant's 


Pyloric  Spasm  367 

Hospital  obtained  excellent  results  from  intranvenous  injections  of 
destrose  solution.  The  stomach  should  be  washed  out  just  before 
the  operation.  More  salt  solution  should  be  given  after  the  opera- 
tion. 

The  feeding  after  operation  is  important.  It  may  be  begun  as 
soon  as  the  baby  recovers  from  the  anesthetic.  The  best  food  is 
human  milk,  at  first  diluted  with  three  parts  water,  the  strength 
being  rapidly  increased.  If  human  milk  is  not  available,  feeding 
should  be  begun  with  whey,  to  which  cream  is  gradually  added  in 
amounts  sufficient  to  give  first  fat  .50%,  then  fat  .75%,  and  then 
fat  1.00%.  The  amount  at  first  should  be  one  drachm  every  hour, 
the  amounts  being  increased  and  the  intervals  lengthened  as  rapidly 
as  possible.  The  conduct  of  the  case  soon  becomes  that  of  any  case 
in  which  chronic  vomiting  has  been  present,  and  is  carried  on  in 
accordance  with  the  principles  of  infant  feeding.  If  the  disease 
has  existed  for  some  time,  the  quantity  of  food  cannot  be  increased 
so  rapidly.  Occasional  vomiting  is  not  a  contraindication  to  in- 
creasing the  food,  but  the  stools  should  be  carefully  watched. 

SPASM  OF  THE  PYLORUS 

In  this  condition,  obstruction  occurs  from  a  spasm  of  the  muscles 
of  the  pyloric  ring.  It  is  more  common  in  infancy  than  is  hyper- 
trophic stenosis  of  the  pylorus,  and  has  often  been  mistaken  for  it. 
It  is  probable  that  most  of  the  cases  in  which  recoveries  from  hyper- 
trophic stenosis  of  the  pylorus  under  medical  treatment  have  been 
reported,  were  really  cases  of  spasm.  Pyloric  spasm  is  distinguished 
from  pyloric  stenosis  by  the  fact  that  in  the  former  there  is  no  con- 
dition of  pathological  anatomy  at  the  pylorus.  Spasm  may  compli- 
cate organic  hypertrophy,  but  such  cases  are  classified  as  stenosis. 

ETIOLOGY. — The  etiology  of  pyloric  spasm  is  very  obscure,  and 
is  very  probably  multiple.  The  principal  etiological  factors  men- 
tioned by  the  various  writers  on  the  subject  are,  i,  nervous  hyper- 
irritabihty,  2,  hyperacidity  of  the  gastric  juice,  and  3,  mechanical 
irritation  from  indigestion.  The  first  theory  is  based  on  the  evidence 
that  the  condition  is  apparently  most  common  in  nervous  and  excit- 
able infants  of  neurotic  heredity.  The  second  theory  is  based  on 
that  fact  that  often  favorable  results  follow  treatment  directed  at 
neutralizing  hyperacidity.  The  third  theory  is  based  on  the  evi- 
dence that  in  the  majority  of  cases  some  disturbance  of  gastric  diges- 
tion precedes  or  accompanies  the  condition  of  spasm,  the  spasm  itself 
being  caused  by  the  influence  of  the  products  of  indigestion  on  the 
normal  muscular  hyperirritability  characteristic  of  early  life.  It  is 
probable  that  all  three  factors  may  play  a  part.  In  my  opinion, 
the  third,  that  of  indigestion,  is  so  important,  that  spasm  might  be 


368  Diseases  of  the  Gastro-Enteric  Tract 

regarded  as  one  symptom  of  indigestion,  appearing  particularly  in 
nervous  infants. 

SYMPTOMS. — The  symptoms  of  pyloric  spasm  are  much  like 
those  of  the  milder  cases  of  h3rpertrophic  stenosis.  The  condition  is 
most  common  in  artificially-fed  babies,  and  the  patients  are  usually 
of  an  irritable,  neurotic  type.  Vomiting  is  the  first  symptom;  it 
may  appear  shortly  after  birth,  but  usually  does  not  appear  for 
several  weeks,  or  even  for  several  months.  The  vomiting  often 
becomes  projectile.  It  is  almost  never  completely  relieved  by  any 
change  in  the  composition  of  the  food,  although  there  may  be  some 
improvement.  The  vomitus  may  or  may  not  show  evidences  of 
indigestion,  and  the  quantity  vomited  does  not  ordinarily  exceed 
the  amount  of  the  last  feeding.  In  mild  cases  vomiting  is  the  only 
important  symptom,  although  there  may  be  some  tendency  to 
constipation. 

In  more  severe  cases,  constipation  is  more  marked,  although  the 
stools  always  show  some  fecal  residue.  Visible  peristalsis  is  often 
present.  In  rare  cases,  a  tumor  may  be  felt  at  the  pylorus,  but  the 
tumor  is  smaller  and  thinner  than  that  of  hypertrophic  stenosis, 
and  during  palpation  may  often  be  felt  to  appear  and  disappear 
under  the  finger.  Roentgenograms  after  a  bismuth  meal,  or  aspira- 
tion with  the  stomach  tube,  shows  exactly  the  same  delay  in  the 
emptying  time  of  the  stomach  as  is  seen  in  hypertrophic  stenosis, 
but  the  X-ray  plates  never  show  evidence  of  complete  occlusion. 

DIAGNOSIS. — Spasm  of  the  pylorus  must  be  differentiated  from 
hypertrophic  stenosis  of  the  pylorus,  indigestion  with  vomiting,  and 
habitual  vomiting. 

Hypertrophic  Stenosis. — The  differential  diagnosis  of  pyloric 
stenosis  and  pyloric  spasm  has  been  fully  considered  under  the  head- 
ing of  the  former  disease.  The  duodenal  catheter,  of  a  size  normal 
for  the  age  of  the  baby,  will  always  pass  in  pyloric  spasm. 

Indigestion. — In  indigestion  there  is  usually  some  evidence  in 
the  vomitus,  the  vomiting  is  rarely  projectile,  and  visible  peris- 
talsis is  not  seen.  The  most  important  evidence  in  doubtful  cases 
is  gained  by  investigating  the  emptying  of  the  stomach,  the  begin- 
ning of  which  is  never  delayed  in  indigestion,  but  is  always  delayed 
in  pyloric  spasm. 

Habitual  Vomiting. — In  this  condition  the  vomiting  usually 
occurs  when  the  baby  is  picked  up,  moved,  or  is  active.  The  vomit- 
ing is  never  projectile,  constipation  is  not  marked,  there  is  no 
visible  peristalsis,  and  no  delay  in  the  emptying  time  of  the  stomach. 

PROGNOSIS. — The  ultimate  prognosis  of  these  cases  is  very 
good;  almost  always  eventual  recovery  occurs.     The  cases,  however, 


Pyloric  Spasm  369 

often   require  long   treatment,    the   symptoms  persisting  for  many- 
weeks,  or  even  months. 

TREATMENT. — The  treatment  of  pyloric  spasm  consists  in  care- 
ful regulation  of  the  diet,  the  giving  of  alkalies,  gastric  lavage,  and 
the  passage  of  the  duodenal  catheter. 

The  best  food  is  human  milk.  When  infants  must  be  artificially 
fed,  the  food  given  must  be  low  in  fat,  not  more  than  .50%  at  first, 
because  excessive  fat  tends  to  delay  the  emptying  time  of  the  stom- 
ach. The  caloric  value  of  such  a  food  is  low,  and  cannot  be  made 
up  by  any  marked  increase  in  carbohydrate,  without  danger  of 
causing  carbohydrate  indigestion.  The  protein  should  be  increased, 
but  the  casein  curds  of  cow's  milk  may  act  as  irritants  to  the  irrit- 
able pyloric  ring;  consequently  whey  mixtures  are  indicated.  A 
formula  of  fat  .50,  lactose  6.00,  whey  protein  .90,  casein  .40,  lime 
water  50%  of  the  cream,  is  a  good  one  to  begin  with.  If  the  symp- 
toms are  relieved,  but  there  is  no  gain  in  weight,  the  fat  must  be 
gradually  increased,  and  later  the  casein  may  be  increased.  I  have 
found  that  in  many  cases  of  pyloric  spasm,  sodium  citrate,  in  the 
amount  of  .40%  of  the  milk  and  cream,  works  better  than  lime 
water.  In  obstinate  cases,  sodium  bicarbonate,  1.70%  of  the  milk 
and  cream,  may  be  tried. 

The  intervals  between  feedings  should  be  longer  than  the  emptying 
time  of  the  stomach,  as  measured  by  X-ray  or  stomach-tube  inves- 
tigation. The  amount  given  must  be  varied,  until  it  is  found  on 
what  quantity  the  baby  does  best. 

Daily  lavage  with  water  or  a  weak  bicarbonate  of  soda  solution 
may  be  tried.  It  may  help  at  times,  but  in  the  majority  of  cases 
it  does  no  good.  Flaxseed  poultices  to  the  epigastrium  have  ap- 
peared to  help  some  cases. 

I  have  had  the  best  results  in  spasm  of  the  pylorus  with  the 
duodenal  catheter.  It  should  at  first  be  passed  once  daily,  and  one 
feeding  may  thus  be  given  directly  into  the  duodenum.  As  the 
symiptoms  improve,  the  catheter  is  gradually  passed  less  often,  and 
finally  its  use  may  be  omitted. 

It  is  possible  that  there  may  be  cases  of  pyloric  spasm  sufficiently 
severe  and  resistant  to  require  surgical  intervention.  I  have  yet  to 
see  a  case  in  which  the  diagnosis  was  confirmed  by  the  duodenal 
catheter,  which  did  not  eventually  do  well  under  medical  treatment. 

PROBLEMS  AND  RESEARCH.— In  the  last  ten  years  various 
studies  on  the  physiology  of  gastric  digestion  have  included  the 
mechanism  of  the  opening  and  closing  of  the  pylorus.  The  pyloric 
reflex  is  probably  closely  connected  with  the  subject  of  spasm  of  the 
pylorus.  Cannon  has  shown  that  on  the  gastric  side  of  the  pylorus, 
when  the  material  is  acid,  the  valve  tends  to  open,  and  when  alkaline 
24 


370  Diseases  of  the  Gastro-Enteric  Tract 

to  close.  On  the  duodenal  side  an  alkaline  reaction  allows  the  valve 
to  open,  and  an  acid  reaction  causes  it  to  close.  Cowie  and  Lyon 
have  found  that  this  opening  and  closing  reflex  could  be  demonstrated 
in  infants.  If  the  food  were  too  strongly  alkaline,  the  opening  reflex 
would  be  delayed,  and  the  food  would  remain  longer  in  the  stomach. 
""This  is  opposed  to  the  theory  on  which  use  of  alkali  in  pyloric  spasm 
is  based,  namely,  that  the  alkalies  in  diminishing  casein  curd  forma- 
tion, allows  the  liquid  contents  to  pass  the  pylorus  more  readily. 
Cannon,  on  the  basis  of  his  experiments,  believes  that  mechanical 
factors  have  little  or  nothing  to  do  with  the  opening  and  closing  of 
the  pylorus.  If  this  explanation  is  true,  it  would  be  possible  to 
exaggerate  the  condition  of  spasm,  by  giving  too  much  alkali,  and 
our  use  of  alkali  would  theoretically  have  to  be  based  on  chemical 
analysis  of  the  gastric  contents. 

DILATATION  OF  THE  STOMACH 

ETIOLOGY. — A  moderate  dilatation  of  the  stomach  is  rather  more 
common  in  infancy  than  in  older  children.  The  higher  degrees  of 
dilatation  are  rare.  It  may  rarely  arise  from  some  obstructive  con- 
dition, such  as  a  stenosis  of  the  pylorus,  but  in  most  cases  is  the 
result  of  errors  in  feeding.  It  is  more  apt  to  occur  when  the  infant 
is  not  nursed,  unless  especial  care  is  taken  to  give  it  the  quantity 
of  food  which  is  adapted  to  its  age  and  gastric  capacity.  When  the 
infant  is  nursed,  the  breast  seems  to  provide  the  amount  of  food 
which  is  suitable.  Dilatation  from  errors  in  feeding  may  be  caused 
by  the  fact  that  the  food  is  not  adapted,  either  in  quality  or  in  quan- 
tity, to  the  needs  of  the  individual  infant.  When  the  quality  is  at 
fault,  the  nutrition  of  the  tissues  of  the  stomach  is  interfered  with, 
and  its  w^alls  become  weak,  and  are  thus  more  easily  distended  by 
the  gas  which  results  from  the  abnormal  changes  in  the  food.  In 
this  way  dilatation  occurs.  This  class  of  cases  is  notably  represented 
in  rachitis,  in  which  dilatation  of  the  stomach  takes  place  very 
readily. 

When  the  quantity  of  the  food  is  not  properly  adapted  to  the 
size  of  the  stomach,  dilatation  can  take  place  in  even  a  healthy 
infant,  so  that  the  careful  regulation  of  the  amount  of  food  which 
is  given  at  each  feeding  during  the  first  year  of  life  is  most  important. 

PATHOLOGICAL  ANATOMY.— The  pathological  condition 
which  exists  in  cases  of  gastric  dilatation  is  well  represented  in 
Fig.  89. 

SYMPTOMS. — The  symptoms  of  dilatation  of  the  stomach  are 
essentially  those  of  chronic  indigestion.  Vomiting  is  quite  frequent, 
and  continues  until  the  stomach  has  been  entirely  emptied,  when  a 
period  of  rehef  comes,  to  last  until  fresh  irritation  arises  from  another 


Dilatation  of  the  Stomach 


371 


supply  of  food.  Abdominal  pain,  flatulence,  and  general  discom- 
fort are  prominent  symptoms.  Rapid  loss  in  weight  and  emaciation 
also  occur.  In  rare  cases,  in  young  infants,  convulsions  may  arise, 
apparently  due  to  the  reflex  disturbance  which  is  produced.  When 
a  dilatation  is  of  a  high  grade,  the  vomiting  may  occur  only  after 
considerable  intervals,  and  the  amount  vomited  is  greater  than  that 


Dilated  stomach.     Rachitic  infant,  7  months  old.     (Actual  size) 

of  a  single  feeding,  and  may  be  very  laTge.  In  dilatation  of  the 
stomach,  the  greater  curvature  is  so  much  increased  and  depressed 
below  the  level  of  the  pyloric  orifice  that  a  pouch  is  formed.  The 
food,  collecting  in  this  pouch  as  though  it  were  at  the  bottom  of  a 
well,  has  to  be  practically  pumped,  by  the  contraction  of  the  muscular 
walls,  up  to  and  through  the  pyloric  orifice.     The  already  weakened 


372 


Diseases  of  the  Gastro-Enteric  Tract 


stomach  thus  has  to  perform  work  for  which  it  is  not  fitted,  and 
finally  is  relieved  by  spasmodic  vomiting.  When  only  the  small 
amount  of  food  adapted  to  their  normal  gastric  capacity  is  given  to 
young  infants  whose  stomachs  are  dilated,  a  large  space  of  empty 
stomach  is  left  above  the  level  of  the  liquid  which  has  entered  the 
stomach.  This  creates  a  feeling  of  emptiness  and  general  discom- 
fort, so  that  the  infant  appears  to  be  hungry  when,  in  fact,  it  is  only 
suffering  from  the  feeling  of  incomplete  filling  of  the  stomach. 


Dilatation  of  stomach.     Age  6  years 


Physical  Examination. — On  inspection  the  abdomen  is  seen  to 
be  distended  and  tense,  and  on  percussion  to  be  highly  tympanitic 
in  its  upper  part.  Succussion  is  not  an  especially  valuable  diag- 
nostic sign  in  dilatation  of  the  stomach.  Succussion  is  so  frequently 
found  in  many  conditions,  and  is  so  likely  to  be  confounded  with 
that  which  occurs  in  the  colon,  that  it  cannot  be  relied  upon.     The 


Dilatation  of  the  Stomach  373 

outlines  of  a  normal  stomach  when  it  is  somewhat  distended  vary 
so  much  during  infancy  that  the  results  of  percussion  are  often  very 
misleading.  When,  however,  the  tympanitic  resonance  is  found  to 
extend  below  the  line  of  the  umbilicus,  we  may  suspect  that  we  are 
dealing  with  gastric  dilatation,  but  even  then  it  is  uncertain  whether 
it  is  the  gastric  tympany  which  we  have  obtained.  In  infancy  the 
cardiac  end  of  the  stomach  is  so  sHghtly  developed  that  any  great 
increase  in  the  area  of  gastric  resonance  on  the  left  side  is  an  im- 
portant aid  in  making  the  diagnosis. 

DIAGNOSIS. — The  differential  diagnosis  is  to  be  made  chiefly 
from  dilation  of  the  colon.  In  many  cases  when  the  colon  is  dilated 
it  is  impossible  to  determine  whether  the  stomach  is  also  dilated, 
since  under  these  circumstances  the  colon  can  almost  completely 
cover  a  largely  dilated  stomach. 

The  most  important  diagnostic  symptom  is  the  vomiting  of  exces- 
sively large  quantities  of  food.  The  positive  diagnosis  of  the  condi- 
tion is  based  on  the  result  of  a  roentgenogram  taken  after  a  bis- 
muth meal. 

PROGNOSIS. — If  the  dilatation  is  due  to  congenital  stenosis  of 
the  pylorus  the  prognosis  is  that  of  stenosis.  In  other  cases  the 
prognosis  depends  upon  whether  the  condition  arises  from  improper 
amounts  of  food  or  from  some  disease,  such  as  rachitis.  In  the 
former  class  the  prognosis  is  good,  and  the  stomach  under  a  proper 
regulation  of  the  diet  soon  assum^es  its  natural  size.  In  the  second 
class  it  is  good,  although  as  a  rule,  the  stomach  will  remain  more 
or  less  distended  until  the  disease  which  causes  the  dilatation  has 
been  cured. 

TREATMENT. — If  the  case  is  an  obstinate  one,  lavage  is  an 
important  part  of  the  treatment.  In  many  cases,  however,  good 
results  are  obtained  simply  by  regulating  the  quaHty  and  quantity 
of  the  food.  When  the  food  is  first  given  in  the  proper  amount  it 
will  not  fill  the  stomach  nor  satisfy  the  demands  of  the  infant.  Under 
these  circumstances  the  infant  will  be  very  restless,  and  will  often 
cry  almost  continuously  from  the  time  of  one  feeding  until  the  next. 
The  nurse  must  be  made  to  understand  that  these  signs  of  discom- 
fort are  liable  to  last  for  a  number  of  days,  until  the  stomach  has 
more  nearly  resumed  its  normal  size,  and  that  an  additional  supply 
of  food  must  not  be  given  to  the  infant  simply  because  it  cries  for 
more. 

CONTRACTION  OF  THE  STOMACH 

In  certain  cases  the  capacity  of  the  stomach  is  decidedly  dimin- 
ished. The  diminution  in  size,  as  a  rule,  depends  upon  a  lack 
of  use,  such  as  occurs  in  infantile  atrophy.     Sufficient  food  to  fill 


374 


Diseases  of  the  Gastro-Enteric  Tract 


the  stomach  is  not  taken,  and  in  this  way  the  stomach  is  not  called 
upon  to  perform  its  normal  work.  In  cases,  also,  in  which  there  is 
continuous  vomiting,  this  same  lack  of  use  may  produce  a  diminu- 
tion in  the  size  of  the  stomach.  These  cases  are  of  pathological 
rather  than  of  clinical  interest,  as  they  can  seldom  be  diagnosticated, 
and  their  treatment  is  essentially  that  of  the  especial  disease  to 
which  they  are  secondary. 

DILATATION  AND  HYPERTROPHY  OF  THE  COLON 

(Hirschprung's  Disease.)     (Idiopathic  Dilatation  of  the  Colon.) 

This  disease  consists  in  a  very  marked  condition  of  dilatation 
and  hypertrophy  of  the  whole  or  of  a  part  of  the  large  intestine. 

Fig.  91 


Hirschprung's  Disease.     Section  through  the  colon  showing  enormous  widening 
of  the  muscular  layers,  particularly  of  the  muscularis  mucosae 

ETIOLOGY. — The  etiology  of  the  condition  is  unknown.  The 
most  widely  held  theory  is  that  it  is  a  primary  congenital  malforma- 
tion. Some  writers  beheve  that  it  may  in  some  cases  at  least,  rep- 
resent a  secondary  or  acquired  condition,  due  to  some  slight  and 
hardly  recognizable  obstruction.  The  sigmoid  flexure  of  infants  is 
normally  longer  than  that  of  adults,  and  it  is  conceivable  that  in  an 
especially  long  one,  kinks  might  occur,  which  would  lead  to  accumu- 
lation of  feces  and  gas,  to  dilatation,  and  eventually  to  compensatory 


Hirschpruxg's  Disease 


375 


h}'pertrophy.  Or,  the  cause  of  the  stoppage  might  be  in  the  rectum. 
Against  the  theory  of  a  secondary  etiology  is  the  fact  that  the  symp- 
toms usually  appear  very  soon  after  birth,  and  that  in  the  cases 
which  have  come  to  autopsy,  no  constriction  has  been  found  in  the 
lower  part  of  the  intestinal  canal.  There  must  be  some  lack  of 
motility,  or  an  incomplete  power  of  contraction,  to  explain  why, 
with  congenital  hj-pertrophy  of  the  muscular  layers,  the  intestines 
are  incapable  of  expelling  their  contents. 

Fig.  92 


Congenital  dilatation  of  the  colon.     (Hirschprunir's  Disease) 

PATHOLOGIC.\L  ANAT0:MY.— The  condition  is  recognized  by 
its  characteristic  pathological  tissue  changes.  These  may  involve 
the  whole  of  the  large  intestine,  or  only  a  part.  The  lesion  macro- 
scopically  shows  as  a  dilatation  and  lengthening  of  the  colon,  with 
marked  thickening  of  its  walls.  ^Microscopically,  the  principal  lesion 
is  a  marked  h^-pertrophy  of  all  the  muscular  layers,  the  thickening 


376 


Diseases  of  the  Gastro-Exteric  Tract 


of  the  muscularis  mucosae  being  especially  conspicuous.     Secondary 
ulceration  of  the  mucous  membrane  is.  often  found  post-mortem. 

SYMPTOiMS.- — The  chief  symptoms  are  distention  of  the  abdo- 
men and  constipation.  Both  symptoms  appear  very  sooil  after 
birth.     The  constipation  is  very  obstinate,  and  patients  have  been 

Fig.  93 


Dilatation  of  colon.     Male,  12  years  old 

known  to  go  as  long  as  two  weeks  without  a  movement  of  the  bowels. 
The  distention  of  the  abdomen  soon  becomes  very  extreme,  but  may 
temporarily  disappear  entirely  if  the  bowels  are  emptied  by  vigorous 
treatment  with  enemata,  and  purgatives.  Visible  peristalsis  is  pres- 
ent at  times. 

Nutrition  suffers  to  a  variable  extent.  Emaciation  may  become 
severe,  or  may  not  be  marked.  At  times  attacks  of  more  acute 
obstruction  may  occur,  with  colic  and  vomiting;  at  other  times  there 
may  be  attacks  of  diarrhea,  the  movements  being  foul,  and  often 


y 


Fig.  94— R()C'nlgcn(),i,rram  of  conKcnijal  flilatal,ion  of  Mic  colon  taken  aflcr  rectal 

injections  of  bismuth 
The  distention  of  the  sigmoid  flexure  is  clearly  shown 


Fig.  95— Roentgenogram  of  congenital  dilatation  of  the  colon  taken  after  a  rectal 

injection  of  bismuth 
The  enlargement  of  the  sigmoid  flexure  and  transverse  colon  is  clearly  shown 


Hirschpruxg's  Disease  377 

containing  pus  and  blood.     Death  may  occur  from  collapse  in  an 
acute  attack,  from  peritonitis,  or  from  some  intercurrent  affection. 

DL\GNOSIS. — The  condition  should  be  suspected  whenever  there 
is  a  history  of  obstinate  constipation  and  enlarged  abdomen  existing 
from  birth.  The  diagnosis  is  confirmed  by  taking  a  roentgenogram 
after  filling  the  colon  through  the  rectum,  with  a  suspension  of 
bismuth. 

PROGNOSIS. — Most  cases  die  in  infancy.  In  a  few  cases,  the 
patients  have  lived  to  adult  life. 

TREATMENT. — Medical  treatment  is  only  palliative.  It  con- 
sists in  the  removal  of  the  accumulated  feces,  and  in  the  prevention, 
as  far  as  is  possible,  of  reaccumulation.  Enemata,  frequently  re- 
peated, should  be  first  used,  and  after  as  much  emptying  as  possible 
has  been  eft'ected,  purgatives  are  used. 

Surgical  treatment  offers  the  only  hope  of  permanent  cure,  but 
the  disease  is  so  uncommon  that  statistics  of  its  results  are  not  yet 
available.  An  artificial  anus  has  been  made  with  temporary  benefit. 
The  ideal  operation  is  removal  of  the  colon,  or  of  the  portion  involved 
in  the  lesion.  The  operation  is  a  very  dangerous  one,  is  attended  by 
severe  shock,  and  will  probably  always  have  a  high  mortality.  Never- 
theless, in  \aew  of  the  bad  prognosis  of  the  disease,  I  believe  operation 
should  be  recommended  in  marked  cases.  It  is  a  good  plan  to  operate 
in  two  stages.  At  the  first  operation  the  anastomosis  between  the 
sound  portions  of  the  bowel  above  and  below  the  lesion  is  made, 
and  a  part  of  the  bowel  is  stitched  to  the  abdominal  wall,  so  that 
if  acute  obstruction  occurs,  an  artificial  anus  may  be  easily  made. 
At  the  second  operation,  the  hypertrophied  colon  is  excised.  The 
results  depend  upon  the  amount  of  colon  involved.  If  the  lesion 
extends  down  to  the  rectum,  the  outlook  is  not  so  good  as  when 
there  is  sound  tissue  available  for  anastomosis  above  and  below 
the  lesion. 

INTUSSUSCEPTION 

Intussusception  is  a  condition  in  which  a  part  of  the  intestine 
is  invaginated  into  another  part.  Under  these  circumstances  there 
is  an  outer  layer  of  intestine  within  which  is  the  part  of  the  intestine 
forming  the  invagination.  Only  a  small  portion  of  the  intestine  may 
be  invaginated,  or  it  may  extend  from  the  ileo-cecal  valve  to  the 
rectum.  Small  invaginations  are  frequently  found  at  the  post- 
mortem examinations  of  infants  and  young  children.  These  prob- 
ably take  place  during  the  death-struggle,  as  no  pathological  condi- 
tion is  found  in  connection  with  them.  This  form  is  usually  mul- 
tiple and  in  the  small  intestine.  The  form  of  intussusception  which 
occurs  during  fife  is  chiefly  a  disease  of  infancy,  but  is  very  rare  under 


378  Diseases  of  the  Gastro-Enteric  Tract 

three  months,  and  is  most  common  from  the  third  to  the  twelfth 
month.  At  this  age  the  large  intestine  is  shorter  in  relation  to  the 
small  intestine  than  in  the  adult,  while  the  mesentery  is  relatively 
longer,  and  thus  allows  much  greater  latitude  for  misplacement, 
especially  of  the  cecum  and  colon.  It  may  occur  in  later  childhood 
in  rare  instances. 

ETIOLOGY. — The  etiology  of  intussusception  is  obscure,  but  it 
is  probably  directly  due  to  increased  local  peristalsis.  Nothnagel 
has  shown  by  experiments  on  animals  that  intussusceptions  are 
formed  by  an  irregular  action  of  the  muscular  layers  of  the  intestinal 
wall.  In  infants,  it  is  probable  that  intussusception  is  produced  in 
the  same  way.  The  disease  is  commonest  in  poorly  nourished  chil- 
dren. While  the  condition  is  not  a  common  one,  it  is  the  most 
frequent  form  of  acute  intestinal  obstruction  seen  in  infancy  and 
childhood. 

PATHOLOGICAL  ANATOMY.— The  pathological  anatomy  de- 
pends upon  the  tightness  of  the  constriction  and  the  length  of  the 
time  from  the  beginning  of  the  obstruction.  In  some  cases  the  in- 
carcerated portion  of  the  intestine  is  so  little  constricted  that  the 
bowel  remains  pervious.  In  other  cases  the  constriction  is  so  great 
that  the  tension  of  the  intestinal  capillaries  quickly  becomes  extreme, 
and  hemorrhage  occurs,  and  inflammation,  with  resulting  adhesions, 
is  apt  to  follow  rapidly.  The  intestine  may  not  only  be  invaginated, 
but  may  be  bent  on  itself,  an  important  point  to  remember  in  regard 
to  treatment. 

SYMPTOMS. — The  symptoms  of  intussusception  are  usually 
acute,  though  often  at  first  rather  obscure.  Often  the  first  thing 
noted,  is  a  condition  resembing  surgical  shock.  The  principal  symp- 
toms are  pain,  vomiting,  and  bloody  stools.  The  onset  is  usually 
with  pain  and  vomiting,  though  occasionally  the  bloody  movements 
are  noted  first.  The  pain  is  paroxysmal,  resembling  a  very  severe 
colic,  and  it  is  present  in  the  majority  of  cases,  though  it  may  be 
absent.  The  vomiting  is  most  severe  at  the  onset,  but  usually  con- 
tinues throughout  the  attack  and  may  become  stercoraceous  in  some 
cases.  There  may  be  one  or  two  fecal  stools  passed  at  the  begin- 
ning, but  soon  they  consist  of  mixed  blood  and  mucus  resembling 
currant  jelly  in  appearance,  and  no  more  fecal  matter  is  passed. 

The  mind  is  clear,  and  in  young  infants  the  face  is  often  tranquil 
between  the  paroxysms  of  pain,  so  that  on  looking  at  the  infant  it 
would  scarcely  be  supposed  that  a  serious  condition  was  present. 
Later,  however,  the  face  grows  haggard  and  the  eyes  become  sunken. 
During  the  first  twenty-four  to  forty-eight  hours,  and  even  longer, 
the  infants  will  often  take  their  food  quite  readily.     Tenesmus  is 


Intussusception  379 

at  times  present.  There  may  be  fever,  especially  when  inflammation 
has  occurred.  The  pulse  is  usually  quickened.  These  symptoms 
all  vary,  and  depend  on  the  amount  of  the  invagination.  In  some 
cases  these  are  the  only  signs  which  indicate  that  there  is  abdominal 
disturbance.  In  most  instances,  however,  either  at  once  or  within 
a  few  hours,  a  tumor  can  be  felt  in  the  abdomen.  The  tumor  is  the 
most  important  sign.  It  may  be  felt  in  various  parts  of  the  abdo- 
men, and  may  often  be  felt  by  rectal  examination.  It  has  even  been 
found  protruding  from  the  anus. 

DIAGNOSIS. — The  chief  points  in  the  diagnosis  of  intussuscep- 
tion are  the  occurrence  of  discharges  of  blood,  vomiting,  abdominal 
pain,  and  the  detection  of  an  abdominal  tumor.  In  these  cases  a 
careful  rectal  examination  should  always  be  made,  for  a  tumor  can 
often  be  found  in  this  way  when  an  external  examination  has  failed 
to  detect  it.  I  have  seen  intussusception  mistaken  for  infectious 
diarrhea.  An  important  diagnostic  point  is  that  in  infectious  diar- 
rhea, the  mucus  is  streaked  or  spotted  with  blood,  while  in  intussus- 
ception the  mucus  and  blood  are  homogeneously  mixed.  No  case 
with  a  history  of  blood  in  the  stools  should  be  allowed  to  pass  with- 
out either  an  actual  inspection  of  the  discharges,  or  a  careful  abdom- 
inal and  rectal  examination. 

PROGNOSIS. — Without  treatment  the  prognosis  is  unfavorable, 
though  there  are  a  certain  number  of  recoveries  by  spontaneous 
reduction,  or  rarely  by  sloughing  of  the  invaginated  portion  of  the 
intestine,  which  is  then  passed  by  the  rectum.  If  death  takes  place, 
it  usually  occurs  about  the  third  or  fourth  day,  or  at  any  rate  within 
a  week,  after  the  incarceration  is  complete.  When  the  incarceration 
is  not  complete  the  infant  may  live  for  many  weeks,  and  in  older 
children  in  rare  instances  the  disease  may  become  chronic. 

TREATMENT. — The  treatment  of  intussusception,  when  the 
diagnosis  has  been  definitely  made,  should  be  immediate,  as  in  no 
other  disease  does  a  delay  result  in  more  serious  consequence.  Food 
and  cathartics  or  laxatives  are  contra-indicated.  Immediate  lapa- 
rotomy is  indicated  in  all  cases.  Attempts  to  reduce  the  intussus- 
ception by  hydrostatic  pressure  are  too  uncertain,  and  may  cause 
unwarranted  delay.  The  results  of  operation  depend  on  how  early 
in  the  course  of  the  disease  it  is  performed.  If  it  is  performed  early, 
the  surgeon  can  often  easily  reduce  the  invagination,  and  the  intes- 
tine may  not  show  such  serious  signs  of  damage  as  to  require  resec- 
tion. In  such  cases,  the  prognosis  is  much  better.  If  the  operation 
is  performed  later,  not  only  will  the  patient's  general  condition  be 
worse,  but  adhesions  will  have  formed,  and  resection  will  be  necessary. 


380 


Diseases  oe  the  Gastro-Enteric  Tract 


VOLVULUS 

By  volvulus  is  meant  a  twisting  or  bending  of  the  intestine.  This 
condition  is  more  apt  to  occur  in  early  life  than  later,  possibly  because 
of  the  greater  proportionate  length  of  the  mesentery  at  this  time, 
which  allows  the  intestine  greater  latitude  of  motion.  It  occurs 
either  by  itself  or  in  connection  with  intussusception,  from  which 
it  is  to  be  differentiated  by  the  absence  of  blood  and  mucus  in  the 
discharges. 

HERNIA 

The  most  common  form  of  hernia  encountered  in  early  life  is  the 
umbihcal  hernia  of  infancy,  which  has  been  described  in  the  Division 
on  Diseases  of  the  Newborn.     Inguinal  hernia  is  sometimes  seen  in 


Fig. 


Worsted  truss  for  the  treatment  of  inguinal  hernia  in  infants 


infants.  It  is  usually  easily  reducible,  but  protrudes  again  when 
the  infant  cries.  A  truss  made  of  a  skein  of  worsted  which  is 
anchored  by  being  passed  around  the  waist,  and  then  passed  through 
the  groin  and  about  the  thigh,  will  often  suffice  to  keep  the  hernia 
in  place  until  spontaneous  recovery  occurs.  If  the  hernia  resists  this 
simple  treatment,  it  becomes  essentially  a  surgical  affection. 


Prolapse  of  the  Rectum  381 

FISSURE  OF  THE  ANUS 

This  condition  is  seen  both  in  infants  and  children,  and  is  not 
very  uncommon.  The  usual  cause  is  constipation.  The  passage  of 
a  large,  hard  stool  causes  a  tear,  and  when  this  is  repeated,  healing 
is  prevented.  External  trauma,  such  as  careless  use  of  a  rectal 
syringe,  or  the  scratching  caused  by  pin-worms,  may  cause  a  similar 
tear,  but  these  fissures  usually  heal  readily,  unless  the  cause  is 
repeated. 

The  fissure  is  a  linear  ulcer,  which  may  be  situated  at  the  muco- 
cutaneous junction,  or  a  short  distance  from  it.  The  chief  symptom 
is  pain,  which  accompanies  defecation,  and  continues  for  some  time 
afterward.  The  patients  dread  a  movement  of  the  bowels,  cry  as 
soon  as  the  impulse  comes,  and  often  resist  the  impulse  so  that  chronic 
constipation  results,  a  condition  which  makes  the  fissure  worse.  A 
young  child  usually  refers  the  pain  to  the  abdomen,  or  some  neigh- 
boring part,  rather  than  to  the  anus.  The  diagnosis  is  easily  made 
by  inspection  of  the  anus. 

TREATMENT.— The  fissure  should  be  touched  with  the  solid 
nitrate  of  silver  stick,  and  the  applications  should  be  repeated  every 
two  days  until  the  lesion  heals.  The  parts  should  be  kept  clean, 
and  constipation  should  be  prevented.  If  these  measures  fail,  the 
sphincter  must  be  stretched  under  anesthesia. 

HEMORRHOIDS 

Hemorrhoids  are  rarely  met  with  in  infancy  and  early  childhood, 
although  they  can  occur.  The  chief  cause,  as  in  adults,  is  chronic 
constipation.  The  treatment  of  the  constipation  is  the  important 
thing  in  childhood.  This,  with  the  ordinary  local  measures,  such 
as  the  application  of  cold  compresses  after  stool,  careful  reduction, 
and  the  application  of  astringent  ointments,  usually  suffices  for  a 
cure.  Operation  should  not  be  necessary  in  early  life,  unless  the 
condition  is  neglected. 

PROLAPSE  OF  THE  RECTUM 

In  this  condition  either  the  mucous  membrane  of  the  rectum, 
or  the  entire  rectal  wall,  protrudes  beyond  the  sphincter.  It  is  a 
condition  seen  almost  exclusively  in  early  life.  It  is  most  common 
in  the  second  and  third  years,  but  may  be  seen  in  younger  infants 
and  in  older  children.  * 

ETIOLOGY. — The  cause  of  the  frequent  occurrence  of  prolapse 
in  early  life  is  the  lack  of  muscular  support  about  the  anus  at  that 
age.     It  is  often  seen  in  atrophied  infants.     The  exciting  cause  is 


382  Diseases  of  the  Gastro-Enteric  Tract 

straining  at  stool,  and  consequently  the  condition  is  met  with  both 
in  constipation,  and  after  diarrhea  with  tenesmus.  Straining  at 
stool  is  at  times  excited  by  reflex  irritation,  and  prolapse  of  the 
rectum  may  be  a  symptom  of  phimosis,  or  of  stone  in  the  bladder. 

SYMPTOMS. — The  prolapse  usually  occurs  when  the  child  has  a 
movement  of  the  bowels.  It  is  usually  easily  reducible,  but  tends 
to  reappear  with  each  bowel  movement,  and  in  pronounced  cases 
may  come  down  at  other  times.  The  appearance  of  the  tumor 
varies  with  the  severity  of  the  case.  In  mild  cases  there  is  simply  a 
protruding  fold  of  mucous  membrane  surrounding  the  anus.  In  the 
majority  of  cases,  there  is  quite  a  large  tumor  of  a  deep,  purplish- 
red  color,  which  bleeds  easily. 

DIAGNOSIS. — The  appearance  of  the  protruding  tumor  at  the 
anus  is  characteristic.  In  rare  cases  intussusception  shows  a  similar 
protrusion,  but  in  prolapse  all  symptoms  of  acute  intestional  obstruc- 
tion are  absent. 

PROGNOSIS. — The  eventual  prognosis  is  good,  but  the  disease 
is  often  obstinate,  and  requires  prolonged  treatment. 

TREATMENT. — Each  time  that  the  tumor  prolapses,  it  should 
be  bathed  with  ice  water,  and  then  carefully  reduced  with  the  oiled 
fingers,  the  central  portion  being  pushed  back  first.  After  reduction 
a  strip  of  adhesive  plaster  three  inches  wide  should  be  applied  in 
such  a  manner  as  to  hold  the  buttocks  tightly  together.  The  child 
should  be  kept  in  bed  for  the  first  week  of  the  treatment.  Later,  it 
should  be  made  to  lie  down  for  about  .half  an  hour  after  defecation. 
Children  who  have  graduated  from  the  diaper,  should  never  be 
allowed  when  at  stool  to  sit  upon  a  chamber,  or  low  chair,  or  upon 
a  water-closet  seat  the  opening  of  which  is  of  adult  size.  They  should 
have  their  own  chair,  with  a  small  opening. 

The  underlying  condition  should  be  treated.  Constipation  should 
be  treated  at  first  by  enemata,  and  then  by  mild  laxatives  sufficient 
to  keep  the  stools  semi-liquid,  but  not  so  strong  as  to  produce  active 
purgation.  The  tenesmus  accompanying  diarrhea  may  be  relieved 
by  small  injections  of  ice  water  containing  tannic  acid.  Supposito- 
ries containing  opium  may  be  necessary  in  more  severe  cases. 

Occasionally,  in  long-standing  cases,  reduction  is  difficult.  It  may 
be  facilitated  by  applying  a  two  per  cent  solution  of  cocaine.  In 
the  most  resistant  cases  the  tumor  should  be  touched  with  the  paquelin 
cautery,  making  a  series  of  radial  linear  markings  about  an  inch  apart. 


IV.     NEW  GROWTHS 

New  growths  in  the  gastro-enteric  tract  are  very  rare  in  infancy 
and  childhood,  and  are  mostly  confined  to  the  myxomatous  polypi 
of  the  rectum. 

Polypus  of  the  rectum  is  more  common  in  early  life  than  at  any 
other  period.  Hemorrhage  from  the  rectum,  when  not  due  to  con- 
stipation, diarrhea,  or  fissure,  usually  arises  from  polypi.  A  careful 
examination  for  this  growth  should  be  made  when  rectal  bleeding 
is  frequent  or  large.  Rectal  polypi  are  of  various  sizes,  and  may 
be  myxofibromata  or  adenomata.  The  surface  of  the  polypus  is 
usually  smooth,  and  the  pedicle  is  often  long  and  thin.  The  diag- 
nosis is  easily  made  by  a  digital  examination.  The  treatment  is 
either  to  twist  or  cut  off  the  polypus.     The  growth  is  not  apt  to  recur. 


V.    NERVOUS  DISTURBANCES 

ETIOLOGY. — The  functions  of  the  digestive  tract  may  be  dis- 
turbed by  influences  acting  through  the  nervous  system.  The 
result  of  such  influences  is  a  secondary  disturbance  of  function.  Both 
the  secretory  and  mechanical  functions  of  the  digestive  system  may 
be  affected.  When  the  secretory  functions  are  disturbed,  the  result 
is  indigestion,  and  the  symptoms  are  indistinguishable  from  those  of 
indigestion.  Consequently,  nervous  disturbance  is  only  one  of  the 
many  causes  concerned  in  the  production  of  indigestion.  When  the 
mechanical  functions  of  the  gastro-enteric  tract  are  disturbed,  the 
results  are  quite  characteristic,  and  both  the  symptoms  and  treat- 
ment are  sufficiently  distinct  from  those  of  indigestion  to  require 
separate  description. 

The  easily  irritated  nervous  system  of  the  young  child  renders 
it  particularly  liable  to  react  to  various  external  stimuli.  There  is 
variation  in  the  excitability  of  the  nervous  system  in  different  indi- 
vidual children.  The  tendency  to  reaction  may  be  increased  by 
errors  in  the  infant's  care  and  routine,  such  as  noisy  surroundings, 
too  much  attention,  and  stories  or  games  of  too  exciting  a  character. 
These  errors  produce  over-irritability  and  over-exhaustion  of  the 
nerve  centers,  which  become  liable  to  abnormal  reaction. 

The  exciting  causes  acting  through  the  nervous  system  to  produce 
gastro-intestinal  symptoms,  are  various.  The  most  common  are 
extremes  of  heat  and  cold.  In  infants  that  is  the  most  common 
factor,  and  the  usual  result  is  diarrhea.  In  such  cases,  the  over- 
heating of  the  baby  affects  the  nerve  centres,  and  the  abnormal 
influences  transmitted  to  the  nervous  mechanism  of  the  intestine 
cause  increased  peristalsis,  without  there  being  any  indigestion. 
The  condition  is  somewhat  analogous  to  a  mild  heat-stroke,  and 
indeed,  in  heat-stroke  or  heat-exhaustion,  diarrhea  of  a  similar 
character  is  frequently  seen  as  a  symptom.  Part  of  the  prevalence 
of  acute  diarrhea  in  the  summer  months  is  due  to  this  cause,  and 
nervous  diarrhea  is  one  of  the  forms  included  under  the  vague 
heading  of  "  summer  diarrhea,"  although  it  is  the  least  common 
and  least  serious  form.  Cold  also  may  produce  an  acute  diarrhea 
through  nervous  influences,  both  in  infants  and  older  children.  A 
sudden  chilling  of  the  surface  of  the  body,  such  as  occurs  when  a 
child  is  exposed  to  a  cold  draught,  falls  into  the  water,  or  even  is 
exposed  to  a  sudden  change  of  temperature  without  proper  modifi- 
cation of  the  clothing,  will  at  times  produce  an  acute  diarrhea. 


Nervous  Vomiting  and  Diarrhea  385 

In  indigestion  the  local  nervous  mechanism  of  the  intestine  is 
stimulated  by  its  abnormal  contents,  and  diarrhea  results.  Pro- 
longed stimulation  from  indigestion  may  lead  to  local  overexcitability 
of  the  nervous  mechanism  governing  peristalsis,  and  such  a  condi- 
tion may  remain  after  the  indigestion  has  been  cured  by  proper 
dietetic  treatment.  The  result  is  a  continuing  diarrhea  which  is 
not  due  to  indigestion,  but  is  of  nervous  origin,  which  clinically 
resembles  the  nervous  diarrhea  from  other  causes,  except  that  it 
is  more  chronic,  and  which  requires  entirely  different  treatment  from 
the  diarrhea  caused  directly  by  indigestion.  Such  a  condition  of 
nervous  diarrhea  may  also  follow  infectious  diarrhea. 

Excitement  and  fright  may  disturb  the  gastro-intestinal  function 
through  the  nervous  system  in  the  same  way  as  extremes  of  heat 
and  cold.  In  excitable  children,  vomiting  is  often  produced  by  fright 
and  excitement.  Nervous  disturbances  occur  both  in  breast-fed  and 
bottle-fed  infants. 

SYMPTOMS. — ^The  two  chief  symptoms  of  nervous  disturbances 
of  the  gastro-enteric  tract  are  diarrhea  and  vomiting. 

NERVOUS  DIARRHEA.— In  nervous  diarrhea  the  stools  are 
increased  in  number  and  diminished  in  consistency.  An  infant 
usually  has  from  five  to  nine  loose  movements  daily.  The  appear- 
ance of  the  stools  is  normal  in  every  way,  except  for  the  more  watery 
consistency.  The  color  and  odor  are  normal,  and  they  do  not  con- 
tain curds,  undigested  masses,  mucus,  nor  blood.  The  diarrhea 
may  cease  spontaneously  after  one  or  two  days,  or,  as  a  result  of  con- 
tinuing irritability  of  the  nervous  mechanism  governing  peristalsis, 
the  diarrhea  may  continue.  There  may  also  in  infants  be  an  ele- 
vation of  the  body  temperature  at  the  onset  in  cases  produced  by 
heat,  but  this  usually  falls  to  the  normal  in  twenty-four  hours. 

In  older  children,  especially  in  the  cases  produced  by  cold,  there 
is  often  a  sudden  attack  of  colic,  with  borborygmus,  followed  by  one 
or  two  forcibly  expelled  loose  movements.  The  attack  usually  ceases 
spontaneously  unless  the  children  are  over-fed.  In  the  type  pro- 
duced by  heat  there  is  simply  a  tendency  to  frequent  loose  movements. 

There  is  a  somewhat  more  chronic  form  of  nervous  diarrhea, 
which  is  the  type  caused  by  the  increased  peristaltic  irritability  left 
behind  after  some  form  of  indigestion  or  infection.  This  form  is 
quite  common,  and  the  symptoms  are  characteristic.  It  is  marked 
by  the  occurrence  of  an  immediate  movement  of  the  bowels  every  time 
an  infant  is  fed.  The  mother  often  reports  that  "  everything  he 
eats  goes  right  through  him."  The  number  of  movements  in  twenty- 
four  hours  is  about  equal  to  the  number  of  feedings,  and  the  physi- 
cian should  suspect  this  condition  in  healthy-appearing  children, 
when  the  number  of  movements  in  twenty-four  hours  is  six,  seven, 


386  Diseases  of  the  Gastro-Enteric  Tract 

or  eight,  and  should  inquire  if  the  bowels  move  with  each  feeding. 
This  form  of  nervous  diarrhea  is  produced  by  the  feeding  entering 
the  stomach  and  duodenum,  and  causing  a  stimulation  of  peristalsis 
which  is  exaggerated  by  the  condition  of  the  nervous  mechanism. 
The  stools  in  this  type  are  like  those  of  the  more  acute  form,  loose, 
but  otherwise  normal  in  appearance. 

NERVOUS  VOMITING.— This  condition  is  occasionally  seen  in 
children  with  excitable,  high-strung  nervous  systems.  The  precipi- 
tating cause  is  usually  emotional  excitement.  Vomiting  occurs  sud- 
denly, without  nausea  or  straining,  and  is  usually  not  repeated. 
The  vomitus  consists  of  the  food  last  taken,  and  shows  no  evidence 
of  indigestion.  The  condition  reminds  one  of  the  vomiting  seen  in 
high  bred  puppies. 

DIAGNOSIS. — The  diagnosis  of  nervous  diarrhea  depends  chiefly 
upon  the  character  of  the  stools,  which  show  no  evidence  of  indi- 
gestion, fermentation,  or  infection.  The  moving  of  the  bowels 
with  each  feeding  is  a  fairly  characteristic  symptom,  but  the  diag- 
nosis should  not  be  made  without  actual  inspection  of  the  stools. 

PROGNOSIS. — The  prognosis  of  both  nervous  diarrhea  and 
nervous  vomiting  is  good.  In  some  cases,  without  proper  treatment, 
nervous  diarrhea  may  continue  for  a  considerable  time,  and  may 
lead  to  some  loss  in  weight. 

TREATMENT. — In  the  acute  type  of  nervous  diarrhea,  infants 
should  be  given  a  dose  of  castor  oil,  one  teaspoonful  in  the  first  six 
months,  two  teaspoonfuls  after  the  age  of  six  months.  After  the 
castor  oil,  the  next  three  or  four  feedings  should  be  withheld,  boiled 
water  being  given  instead.  The  object  of  the  castor  oil  is  not  so 
much  to  empty  the  bowel,  as  to  produce  a  maximum  stimulus  to 
peristalsis,  after  which,  if  food  be  withheld,  peristaltic  irritabihty 
is  lessened.  During  the  period  of  withholding  food,  bismuth  sub- 
nitrate  may  be  given,  in  doses  of  five  grains  every  four  hours,  and 
should  be  continued  after  feeding  is  resumed,  if  there  is  still  any 
tendency  to  loose  movements.  If  the  diarrhea  resists  this  treat- 
ment, paregoric  should  be  given  as  in  the  more  chronic  type. 

In  the  form  of  nervous  diarrhea  due  to  increased  local  peristaltic 
irritability,  in  which  the  bowels  tend  to  move  after  each  feeding, 
small  doses  of  opium  act  almost  like  a  specific.  In  this  more  chronic 
type,  an  initial  dose  of  castor  oil  is  not  indicated,  but  paregoric  should 
be  given  in  small  doses  proportioned  to  the  age  of  the  child.  The 
quantities  to  be  given  every  four  hours  at  the  different  ages  are  the 
following:  —  In  the  first  three  months,  mi;  in  the  second  three 
months.  Mil ;  in  the  second  six  months,  mv;  in  the  second  year,  mx  ; 
after   the   second  year,  mxv   to  xxx,  according   to  age.     Nervous 


Nervous  Vomiting  and  Diarrhea  387 

diarrhea  is  the  only  form  of  diarrheal  disease  in  which  any  opium 
preparation  should  ever  he  part  of  the  routine  treatment.  Its  action  in 
checking  peristalsis  is  specific  for  this  type.  In  cases  in  which  there 
is  any  doubt  as  to  the  diagnosis  of  nervous  diarrhea,  or  any  suspi- 
cion that  any  indigestion,  fermentation,  or  infection  may  be  present, 
it  is  safer  not  to  use  paregoric,  as  in  such  conditions  diarrhea  should 
not  be  checked.  Bismuth  may  be  used  in  place  of  paregoric  in  the 
doubtful  cases.     It  is  less  effective  than  paregoric. 

In  older  children,  nervous  diarrhea  may  be  treated  in  the  same 
way  as  in  infants.  The  condition  is  not  so  persistent,  and  usually 
is  reheved  by  castor  oil  and  the  withholding  of  food.  If  the  diarrhea 
tends  to  continue,  bismuth  is  safer  than  paregoric,  as  the  inspection 
of  the  movements  does  not  give  such  certain  information  as  to  ab- 
sence of  indigestion  as  it  does  in  infancy. 

Nervous  vomiting  requires  no  treatment  other  than  the  correc- 
tion of  any  faults  of  hygiene  which  may  be  contributing  causes  of 
nervous  over-excitability. 


VI.     DISTURBANCES  OF  DIGESTION 

Disturbances  of  digestion  constitute  the  most  common  and  im- 
portant division  of  the  diseases  of  the  gastro-enteric  tract  in  infancy 
and  childhood. 

GENERAL  ETIOLOGY.— A  disturbance  of  digestion  may  be 
caused  by  some  single  etiological  factor,  or  may  be  the  result  of  a 
number  of  etiological  factors  acting  together.  Also,  the  etiological 
factors  which  act  in  different  cases  may  be  entirely  different.  The 
physician  must  be  fully  familiar  with  this  manifold  etiology. 

Lack  of  Development. — The  great  frequency  of  disturbances  of 
digestion  in  early  life  can  only  be  attributed  to  differences  of  anatomy 
and  physiology  in  the  child  and  in  the  adult.  The  digestive  system 
of  the  child,  as  compared  with  that  of  the  adult  shows  a  relative  lack 
of  development,  chiefly  in  function,  though  partly  in  structure.  It 
is  true  that  the  functional  development  of  the  infantile  gastro-enteric 
tract  is  designed  for  and  suited  to  the  digestion  of  human  milk. 
Nevertheless,  it  is  relatively  undeveloped,  and  consequently  sensi- 
tive to  the  action  of  other  etiological  factors,  such  as  improper  regi- 
men of  nursing,  variations  in  the  breast  milk  through  improper 
regimen  of  lactation,  errors  of  hygiene,  and  other  external  influences. 
When  the  food  is  not  human  milk,  but  is  something  else,  for  the 
digestion  of  which  the  infantile  gastro-enteric  tract  is  not  designed, 
the  factor  of  lack  of  development  becomes  all  the  more  important. 

The  lack  of  development  due  to  age  alone,  may  be  regarded  as  the 
constant  underlying  factor  in  the  disturbances  of  digestion.  It  does 
not  act  alone,  but  is  the  cause  whereby  other  etiological  factors  pro- 
duce disturbance  in  children  when  they  would  produce  no  disturb- 
ance in  adults. 

Inherited  Individual  Variations  in  Digestive  Power. — The 
functional  power  of  digestion  is  not  constant.  A  number  of  babies 
cannot  digest  the  same  food  because  they  are  of  the  same  age  or 
weight.  As  suggested  in  the  division  on  Feeding,  there  is  unlimited 
variation  in  the  digestive  powers  and  nutritive  requirements  of  dif- 
ferent individual  babies  and  young  children.  It  is  impossible  to 
say  how  much  of  this  variation  is  inherited,  and  how  much  is  ac- 
quired. There  can  be  no  doubt,  however,  that  part  of  it  is  inherited, 
because  babies  of  the  same  age,  under  the  same  hygienic  surroundings, 
and  with  the  same  food,  often  show  dift'erent  digestive  powers  and 
nutritive  requirements.  It  is  probable  that  inheritance  plays  an 
important  part  in  the  power  of  the  digestive  apparatus  with  which 


Etiology  of  the  Disturbances  of  Digestion  389 

a  baby  is  equipped  at  the  start  of  life.  Indeed  it  would  be  remark- 
able if  it  were  not  so,  and  the  so-called  constitutional  factor  is  be- 
coming constantly  more  and  more  important  in  our  conceptions  of 
etiology. 

Faulty  Hygienic  Surroundings. — The  individual  variation  in 
digestive  power  and  nutritive  requirements  is  further  increased  by 
the  different  hygienic  surroundings  encountered  by  infants  and 
children.  Most  of  the  violations  of  the  rules  of  hygiene  which  are 
requisite  for  the  proper  development  of  young  human  beings,  can 
react  on  the  digestive  system,  and  are,  perhaps,  more  apt  to  exercise 
their  unfavorable  influence  there  than  in  any  other  part  of  the  body. 
Bad  air,  insufficient  fresh  air,  insufficient  sleep,  improper  clothing, 
faulty  care  of  the  mouth  and  teeth,  overstimulation  of  the  nervous 
system,  all  these  have  an  effect  on  the  power  of  digestion.  It  is 
easy  to  see  that  with  a  varying  inheritance  and  with  varying  hygienic 
surroundings,  there  can  be  no  limit  to  the  individual  variation  in 
the  powers  of  digestion. 

Sudden  External  Influences. — The  digestive  power  may  be 
suddenly  lowered  by  influences  from  outside  the  body.  Whereas 
faulty  hygienic  surroundings  produce  a  continual  chronic  condition 
of  lowered  digestive  power,  these  suddenly  acting  influences  produce 
a  temporary  or  acute  lowering  of  digestive  power.  The  most  com- 
mon of  these  sudden  disturbing  influences  acting  from  outside  are 
heat,  cold,  and  exhaustion.  In  the  division  on  Nervous  Disturb- 
ances of  the  Gastro-enteric  Tract,  we  have  seen  how  heat  can  act 
in  deranging  the  mechanical  function  of  the  digestive  canal.  It  can 
also  derange  the  secretory  function,  and  the  result  of  such  derange- 
ment is  indigestion.  Extremely  hot  weather,  especially  under  faulty 
hygienic  conditions,  produces  a  rapid  lowering  of  digestive  power. 
Sudden  changes  of  temperature,  sudden  chilling  of  the  body,  and 
physical  exhaustion,  may  have  the  same  efTect.  These  suddenly 
acting  external  influences  have  a  great  deal  to  do  with  many  of  the 
cases  of  acute  indigestion  which  are  so  common  in  early  life. 

Disease. — Disease  in  other  parts  of  the  body  may  exercise  an 
unfavorable  influence  on  the  digestive  function  at  all  ages,  and  is 
particularly  liable  to  do  so  in  early  life.  Acute  diseases  will  cause 
a  sudden  lowering  of  digestive  power  very  similar  to  that  caused 
by  the  external  influences  just  described.  Chronic  disease  will  cause 
a  chronic  lowering  of  digestive  power  very  similar  to  that  caused  by 
faulty  hygienic  surroundings. 

The  Food. — The  etiological  factors  which  we  have  considered  up 
to  this  point  have  to  do  with  the  digestive  powers  of  infants  and 
children.  The  most  important  of  all  etiological  factors,  however,  is 
the  character  of  the  food  given,  and  tJie  manner  of  its  giving.     The  diges- 


390  Diseases  of  the  Gastro-Enteric  Tract 

tive  system  of  the  infant  is  designed  for  human  milk,  but,  under 
modern  conditions  of  Hfe,  the  quahty  of  human  milk  is  not  always 
what 'it  should  be.  Faulty  inheritance,  faulty  hygienic  surroundings, 
sudden  disturbing  influences  from  outside,  and  disease — all  these 
factors  may  act  upon  the  mother  as  well  as  upon  the  child.  The 
result  of  their  action  on  the  mother  may  be  an  acute  or  chronic  dis- 
turbance of  the  function  of  lactation,  leading  to  a  sudden  and  tem- 
porary, or  gradual  and  continual,  abnormal  change  in  the  quality 
of  the  breast  milk.  This  may  either  alone  or  in  conjunction  with 
other  etiological  factors,  produce  acute  or  chronic  disturbance  of 
digestion  in  the  infant.  Nevertheless,  so  much  more  perfectly  adapted 
is  human  milk  to  the  digestive  apparatus  of  infants,  than  is  any  other 
food,  that  disturbances  of  digestion  are  very  much  less  common  in 
breast-fed  babies  than  in  the  artificially  fed. 

When  the  food  given  to  an  infant  is  not  human  milk,  it  is  a  foreign 
body,  as  far  as  the  physiology  of  the  infantile  digestion  is  concerned. 
That  such  food  is  a  foreign  body  does  not  mean  that  it  is  necessarily 
incapable  of  digestion.  Whether  or  not  it  is  properly  digested  de- 
pends largely  on  its  composition.  If  it  is  carefully  prepared,  in 
accordance  with  the  principles  described  in  the  Division  on  Feeding, 
it  will  often  be  digested  as  well  as  if  it  were  not  a  foreign  body. 
Nevertheless,  it  is  never  as  good  a  theoretical  food  as  is  human  milk, 
and  no  matter  how  carefully  it  is  prepared,  one  or  more  of  the  fac- 
tors described  above,  such  as  inherited  weakness  of  digestion,  external 
disturbing  influence,  faulty  hygiene,  or  disease,  may  cause  an  inability 
to  digest  a  food  which  is  essentially  a  foreign  body.  It  is  for  this 
reason  that  disturbances  of  digestion  are  so  much  more  common  in 
artificially  fed  infants,  even  when  the  composition  of  the  food  is 
carefully  regulated. 

When  the  composition  of  an  artificial  food  is  not  carefully  regu- 
lated in  accordance  with  the  principles  described  in  the  Division 
on  Feeding,  it  is  much  more  apt  to  act  as  a  foreign  body,  and  hence, 
not  to  be  properly  digested.  In  some  babies,  the  constitutional 
power  of  digestion  is  so  good,  that  even  with  food  not  of  proper 
quality,  disturbance  of  digestion  does  not  occur.  More  often,  how- 
ever, if  some  grave  offense  against  the  principles  of  feeding  is  com- 
mitted, indigestion  will  result. 

In  older  children,  whose  diet  is  more  varied,  the  same  principles 
apply.  The  quality  of  the  food  given  may  be  good,  carefully  regu- 
lated in  accordance  with  the  proper  principles  of  feeding,  and  yet 
the  other  factors  influencing  the  power  of  digestion  may  cause  dis- 
turbance. On  the  other  hand,  in  children  with  good  digestive  power, 
the  quality  of  the  food  may  be  so  improper,  that  indigestion  may 
be  produced,  and  in  older  children  the  opportunity  for  dietetic  errors 
is  very  great. 


Etiology  of  the  Disturbances  of  Digestion  391 

Not  only  is  the  quality  of  the  food  important,  but  also  the  manner 
of  its  giving.  If  it  be  given  in  excessive  quantity,  the  difificulties 
attending  its  digestion  are  exaggerated,  and  indigestion  may  result. 
Simple  overfeeding  is  one  of  the  commonest  causes  of  indigestion. 
If  the  food  be  given  at  irregular  and  improper  intervals,  this  also, 
is  likely  to  result  in  disturbance  of  the  function  of  digestion. 

It  is  often  difficult  to  draw  a  distinction  between  the  food  as  a 
factor  in  disturbed  digestion,  and  the  various  factors  which  lower 
the  digestive  power.  It  is  a  disturbance  in  the  relation  of  the  food 
given  to  the  digestive  power  which  causes  the  disease.  The  cause 
may  lie  chiefly  or  wholly  in  the  food,  or  chiefly  or  wholly  in  the 
digestive  power  of  the  individual  child. 

Bacteria. — The  role  of  bacteria  in  the  disturbances  of  digestion 
is  one  of  the  unsettled  problems  in  the  nutritional  diseases  of  in- 
fancy. The  intestinal  canal  is  normally  the  home  of  a  great  variety 
of  bacteria,  belonging  for  the  most  part  to  the  class  of  saprophytes, 
or  at  any  rate,  leading  a  saprophytic  existence,  and  deriving  their 
nutriment  from  the  food  contents  of  the  intestine  rather  than  from 
the  tissues  of  the  host.  A  certain  amount  of  bacterial  fermenta- 
tion is  therefore  constant  and  normal  in  the  intestinal  canal.  The 
most  generally  accepted  theory  is,  that  under  normal  conditions,  the 
numbers  of  the  various  varieties  of  microorganisms  are  so  balanced 
one  against  another,  that  bacterial  fermentation  not  only  does  no 
harm,  but  is  possibly  a  condition  essential  to  proper  digestion. 

It  has  been  shown  that  in  vitro,  the  growth  of  many  of  the  varieties 
of  bacteria  found  in  the  intestine  may  be  influenced  favorably  or 
unfavorably  by  changes  in  the  chemistry  of  the  culture  media  on 
which  they  are  grown.  It  is  probable  that  a  similar  eft'ect  may  be 
produced  in  the  intestinal  canal  by  changes  in  the  chemistry  of  the 
food.  Such  changes  in  the  chemistry  of  the  food  which  enters  the 
intestine  may  be  produced  by  overfeeding  with  the  different  food 
elements,  fat,  carbohydrate,  or  protein,  or  by  indigestion  in  the 
stomach  or  intestine.  The  result  of  changes  in  the  chemistry  of 
the  food  would  be  a  disturbance  of  the  normal  bacterial  balance, 
an  excessive  predominance  of  certain  varieties  of  bacteria  over  other 
varieties,  and  an  excess  of  some  particular  kind  of  fermentation. 
It  is  conceivable  that  the  same  condition  of  bacterial  fermentation 
of  a  particular  kind  might  be  produced  by  the  introduction  from 
without  in  the  food,  of  a  large  number  of  bacteria  belonging  to  one 
of  the  varieties  normal  to  the  intestine,  or  by  the  introduction  of 
a  smaller  number  of  some  variety  which  is  not  a  normal  inhabitant. 
The  relative  importance  of  disturbance  of  the  bacterial  balance  from' 
changes  in  the  chemistry  of  the  intestinal  contents,  and  from  the 
introduction  of  bacteria  from  without,  is  not  known.     The  evidence 


392  Diseases  of  the  Gastro-Enteric  Tract 

is  in  favor  of  the  greater  importance  of  changes  in  the  chemistry  of 
the  intestinal  contents,  and  if  this  is  so,  abnormal  bacterial  changes 
are  secondary  to  other  forms  of  indigestion. 

PATHOLOGY.  How  the  Various  Etiological  Factors  Pro- 
duce Disease. — Disturbance  of  digestion  results  from  lack  of  bal- 
ance between  the  digestive  power  and  the  food  given,  with  or  without 
the  added  factor  of  abnormal  bacterial  fermentation.  The  changes 
produced  by  this  lack  of  balance,  with  or  without  fermentation,  are 
for  the  most  part  chemical.  Symptoms  of  the  disturbance  are  pro- 
duced in  three  ways.     They  are  the  following: — 

1.  Irritation  of  the  mucous  membrane. 

2.  Disturbance  of  metabolism. 

3.  Absorption  of  toxic  products. 

Irritation. — The  irritation  of  the  mucous  membrane  in  indiges- 
tion may  be  purely  mechanical.  If  a  young  child  eats  a  quantity 
of  pickles  or  cucumbers,  it  is  not  any  chemical  change  in  the  food 
which  produces  the  trouble,  but  the  mechanical  irritation  of  a  sub- 
stance which  in  the  dehcate  stomach  or  intestine  of  early  life,  acts 
as  a  foreign  body.  Similarly,  if  an  excessive  quantity  of  casein 
is  not  digested,  the  curds  may  produce  symptoms  by  mechanical 
irritation. 

Very  often,,  however,  it  is  the  chemical  changes  in  the  food  con- 
tents which,  in  indigestion,  produce  irritation  of  the  mucous  mem- 
brane of  the  gastro-enteric  tract.  Excessive  bacterial  fermentation 
also  may  result  in  the  formation  of  products  which  are  not  absorbed, 
but  act  purely  as  chemical  irritants.  It  is  impossible  to  separate 
the  chemical  changes  produced  in  the  food  by  pure  disturbance  of 
the  chemistry  of  digestion,  from  those  produced  by  abnormal  bac- 
terial fermentation. 

The  anatomical  changes  produced  by  the  irritation  of  the  mucous 
membrane  in  indigestion  are  unimportant,  and  bear  no  constant 
relation  whatever  to  the  etiological  factors  involved.  Very  often 
there  are  no  macroscopic  changes  whatever.  There  may  be  conges- 
tion of  the  mucous  membrane,  excessive  secretion  of  mucus,  or  some 
desquamation  of  the  epithelium.  In  a  few  cases  of  long-standing, 
or  cases  in  which  mechanical  irritation  was  excessively  severe,  there 
may  be  folHcular,  or  even  ulcerative,  ileo-colitis,  the  lesions  resemb- 
ling those  seen  in  -the  infections. 

Disturbance  of  Metabolism. — The  most  important  effect  of 
indigestion  is  disturbance  of  the  general  metabolism  of  the  body. 
One  of  the  most  important  steps  in  advance  in  the  progress  of  our 
knowledge  was  the  recognition  of  the  fact  that  the  function  of  diges- 
tion cannot  be  considered  apart  from  that  of  the  general  metabolism. 
It  is  to  European  writers  that  we  chiefly  owe  this  advance.     For  a 


Pathology  of  the  Disturbances  of  Digestion  393 

long  time  they  have  been  classifying  functional  disturbances  of  the 
gastro-enteric  tract  under  the  general  heading  of  disturbances  of 
nutrition.*  The  relation  of  general  metabolic  and  nutritional  dis- 
turbances to  particular  food  elements  led  in  Europe  to  the  wide- 
spread acceptation  of  the  idea  of  a  chemical  "food  injury." 

The  changes  in  the  metabolic  processes  of  the  body  which  are 
produced  by  disturbed  digestive  function,  are  as  yet  very  imper- 
fectly understood,  and  are  the  subject  of  much  scientific  investig- 
tion  at  the  present  day.  They  are  not  recognizable  by  any  anatom- 
ical changes.  The  most  important  fact  which  has  been  established 
is  that  these  disturbances  of  metabolism  vary  according  to  which 
of  the  food  elements  is  most  concerned  in  indigestion.  Disturbance 
of  metaboHsm  may  be  produced  by  failure  of  absorption,  by  the 
absorption  of  abnormal  chemical  products,  and  by  the  excessive 
secretion  into  the  intestine  of  chemical  substances  belonging  in  the 
circulating  blood.  The  exact  nature  of  the  various  disturbances  is 
probably  very  compHcated.  The  first  and  principal  result  of  dis- 
turbed metaboHsm,  is  disturbance  of  the  general  nutrition  of  the 
body.  A  second  result  is  the  production  of  a  toxemia,  which  may 
be  due  to  a  relative  increase  of  some  substance  normally  held  in 
proper  balance,  or  to  the  formation  of  toxic  metabolic  products. 

The  important  point  to  remember  is  that  the  disturbances  of  meta- 
bolism and  their  results,  produced  by  indigestion,  vary  according  to 
the  food  ele7nent  which  is  in  relative  excess. 

Fermentation. — It  is  probable  that  every  change  in  the  chem- 
istry of  the  intestinal  contents  is  accompanied  by  some  abnormality 
of  bacterial  life, — some  degree  of  fermentation.  It  is  when  the 
symptoms  produced  by  bacterial  fermentation  come  to  dominate  the 
clinical  picture,  that  bacterial  processes  become  important.  The 
products  of  abnormal  bacterial  fermentation  can  act  in  two  ways 
in  producing  sj^mptoms.  The  first  is  by  simple  irritation  of  the 
mucous  membrane  of  the  gastro-enteric  tract,  and  in  this  way  the 
manner  of  action  is  similar  to  that  of  the  abnormal  chemical  pro- 
ducts of  digestion,  when  they  irritate  the  mucous  membrane,  and 
the  symptoms  produced  are  also  similar.  The  second  mode  of 
action  is  seen  when  the  products  of  bacterial  fermentation,  instead 
of  being  only  locally  irritant,  are  actuall}^  toxic.  Their  absorption 
then  produces  a  toxemia,  the  symptoms  of  which  are  much  like 
those  of  the  toxemia  sometimes  produced  by  disturbance  of  the 
general  body  metabolism. 

When  bacteria  enter  the  tissues  of  the  intestine,  or  produce  definite 
lesions,  the  condition  is  classified,  not  under  disturbances  of  diges- 
tion, but  under  infection. 

*  Cf.  Czerny-Keller.  Des  Kindes  Ernahrung,  Ernalirung^krankheiten  und  Ernah- 
rungstherapie. 


394  Diseases  of  the  Gastro-Enteric  Tract 

CLASSIFICATION  OF  THE  DISTURBANCES  OF  DIGES- 
TION.— It  is  obvious  that  the  disturbances  of  digestion  cannot  be 
classified  upon  the  basis  of  their  pathological  anatomy,  as  in  them 
there  are  no  lesions  characteristic  of  the  various  causes  and  pro- 
cesses. Classification  upon  the  basis  of  symptoms,  is  entirely  un- 
scientific. In  spite  of  the  manifold  etiology,  our  efforts  at  treat- 
ment are  directed  at  removing  the  cause,  and  the  essential  etiologic 
factors  which  we  have  to  combat  are,  relative  overfeeding,  and 
bacterial  fermentation.  We  have  seen  that  the  disturbances  of 
metabolism  produced  by  indigestion  vary  with  the  particular  food 
element  which  is  in  relative  excess,  while  an  excess  of  food  as  a 
whole  may  produce  indigestion  from  simple  irritation.  In  some 
cases,  excessive  bacterial  fermentation  dominates  the  clinical  picture. 

Upon  this  basis,  the  following  classification  was  adopted  by  the 
Pediatric  Department  of  the  Harvard  Medical  School.* 

Classification  of  the  Disturbances  of  Digestion 

1.  Indigestion  from  an  excess  of  food. 

2.  Indigestion  from  an  excess  of  an  individual  food  element. 

a.  Fat. 

b.  Carbohj'drate. 

c.  Protein. 

d.  Salts. 

3.  Indigestion  with  fermentation 

Finkelstein's  Classification. — The  disturbances  of  nutrition 
associated  with,  gastro-intestinal  symptoms  have  been  looked  upon 
by  Finkelstein  from  a  point  of  view  differing  somewhat  from  that 
on  which  the  above  classification  is  based.  His  ideas  have  been  so 
clearly  and  forcibly  expressed,  that  they  have  occupied  a  large  place 
in  recent  pediatric  literature,  and  have  strongly  appealed  to  many 
pediatrists.  For  this  reason,  a  brief  discussion  of  his  grouping  of 
these  nutritional  disorders,  and  of  its  relation  to  the  classification 
used  in  this  book,  may  be  useful  to  some  readers. 

The  basis  of  Finkelstein's  classification  is  the  way  infants  react 
to  food,  and  the  various  groups  into  which  he  divides  infants  are 
based  upon  their  apparent  functional  capacity.  He  deduces  his 
theories  as  to  etiology,  and  the  nature  of  the  metabolic  disturbances 
produced,  from  the  reaction  to  feeding. 

Finkelstein  divides  nutritional  disorder  into  four  stages,  or  de- 
grees, as  follows:  i.  Bilanzstoriing  (disturbed  equilibrium) ;  2.  Dys- 
pepsie;  3.  Dekompbsition;  4.  Intoxikation. 

In  the  first  stage  caused  by  lowered  tolerance  for  fat,  that  of  dis- 
turbed equilibrium,  there  is  a  failure  of  the  normal  gain  in  weight, 
and  fluctuations  in  the  weight  curve  continue,  until  either  an  ad- 
justment occurs  between  the  food  given  and  the  digestive  power,  or 

*  Morse  and  Talbot.  Diseases  of  Nutrition  and  Infant  Feeding.  The  Macmillan 
Co.     1915. 


Classification  of  the  Disturbances  of  Digestion        395 

until  a  more  serious  stage  supervenes.  The  temperature  variations 
are  wider  than  normal.  The  tolerance  for  food  is  reduced,  and 
attempts  to  attain  a  gain  in  weight  by  giving  more  food  are  not 
successful,  and  may  produce  more  serious  symptoms.  In  the  second 
stage,  that  of  dyspepsia,  which  comes  on  when  the  first  stage  is  not 
ended  by  proper  adjustment,  definite  symptoms  of  indigestion  are 
present.  The  cause  is  the  development  of  intolerance  for  carbohy- 
drate. Diarrhea  is  the  most  common  symptom,  and  the  stools 
are  green,  and  contain  mucus.  There  is  moderate  loss  of  weight 
in  this  stage,  and  occasional  elevation  of  temperature.  The  toler- 
ance for  food  is  still  further  reduced,  as  is  shown  by  the  fact  that 
attempts  to  give  more  food  aggravate  the  symptoms.  In  the  third 
stage,  that  of  decomposition,  the  loss  of  weight  is  rapid  and  marked, 
the  temperature  is  usually  subnormal,  and  the  stools  are  of  bad 
character.  The  tolerance  for  food  is  reduced  to  a  minimum.  It 
should  be  remarked  that  when  Finkelstein  uses  the  term  decomposi- 
tion, he  does  not  refer  to  bacterial  decomposition  of  the  food  in  the 
intestine,  but  to  the  decomposition  of  the  tissues  of  the  body  which 
occurs  as  a  result  of  the  food  intolerance.  The  fourth  stage,  that 
of  intoxication,  is  reached  when  there  is  a  complete  break-down  of 
all  the  processes  of  nutrition,  an  advanced  failure  of  metaboHsm, 
with  the  formation  of  toxic  products. 

Valuable  Features  of  Finkelstein's  Theories. — The  various 
groups  described  by  Finkelstein  undoubtedly  represent  clinical  t^^^es 
commonly  seen  in  mild,  moderate,  and  severe  disturbances  of  nutri- 
tion. We  owe  Finkelstein  a  great  debt  of  gratitude  for  so  vigor- 
ously calling  attention  to  the  fact  that  a  "food  injury"  causes  a 
disturbance  of  the  entire  metabolism  of  the  body.  He  points  out 
clearly  that  under  certain  conditions,  the  tolerance  for  certain  food 
elements  may  be  so  greatly  lowered  that  even  very  small  quantities 
may  be  injurious,  and  may  produce  through  disturbance  of  metabol- 
ism, certain  severe  symptoms  which  are  in  no  way  dependent  upon 
the  action  of  bacteria.  The  first  three  stages  represent  conditions 
with  which  we  in  this  country  have  long  been  familiar,  though  pos- 
sibly under  different  names.  The  description  of  the  fourth  stage, 
that  of  intoxication,  is  particularly  valuable.  We  have  been  too 
prone  in  this  country  to  attribute  toxic  symptoms  in  nutritional 
disorders  to  the  results  of  bacterial  processes  only,  whether  of  infec- 
tion or  of  fermentation.  It  is,  I  beheve,  a  valuable  correction  to 
our  views,  to  realize  that  intoxication  can  also  be  produced  entirely 
by  disturbance  of  metabolism. 

Objections  to  Finkelstein's  Classification. — The  principal 
objection  to  Finkelstein's  classification  is  that  it  entirely  excludes 
the  other  ways  that  indigestion  may  cause  symptoms,  namely,  by  simple 


396  Diseases  or  the  Gastro-Enteric  Tract 

irritation,  and  by  permitting  abnormal  bacterial  fermentation.  He 
regards  the  protein  of  cow's  milk  as  practically  incapable  of  pro- 
ducing injury,  yet  we  know  that  in  young  babies,  the  casein  may 
be  the  cause  of  symptoms.  The  reason  he  regards  the  protein  as 
innocuous  is  that  it  does  not  produce  severe  disturbance  of  meta- 
boKsm,  but  probably  acts  either  by  simple  irritation,  or  by  producing 
a  disturbance  of  the  bacterial  balance.  He  regards  the  fat  and 
carbohydrate  as  mainly  responsible  for  the  severer  grades  of  intol- 
erance. While  this  is  true  to  a  large  extent,  some  of  the  conclu- 
sions as  to  the  manner  in  which  the  carbohydrate  at  least  causes 
injury,  have  not  been  justified.  His  entire  description  of  nutritional 
disorders  would  apply  to  what  I  shall  describe  as  indigestion  from 
excess  of  fat. 

The  entire  exclusion  of  bacterial  fermentation  is  probably  not 
justified.  The  relative  roles  of  chemical  food  injuries  affecting 
metabolism,  and  bacterial  fermentation,  are  still  an  unsettled  ques- 
tion, lacking  convincing  evidence.  It  is  probable  that  both  processes 
find  an  important  part  to  play  in  nutritional  disorders. 

"Alimentary  Intoxication." — I  cannot  leave  the  subject  of  the 
views  of  Finkelstein  and  his  followers,  without  some  further  dis- 
cussion of  the  condition  described  by  him  as  "alimentary  intoxica- 
tion." The  condition  is  familiar  to  every  one,  although  marked 
differences  of  opinion  exist  as  to  its  cause,  and  consequently  as  to 
the  name  to  be  applied  to  its  description.  It  is  characterized  by 
diarrhea  and  toxic  symptoms.  Restlessness,  sleeplessness,  and  signs 
or  irritation  of  the  central  nervous  system  are  common;  frequently 
stupor  comes  on,  which  may  deepen  into  coma.  As  Howland  has 
pointed  out,  respiratory  symptoms  are  often  present,  especially  toward 
the  close  of  the  disease.  Such  symptoms  vary  from  a  slightly  in- 
creased ventilation  of  the  lungs  to  very  marked  dyspnea.  Post- 
mortem the  lesions  found  are  very  slight. 

There  are  three  views  as  to  the  cause  of  this  symptom-complex. 

The  first  is  that  of  Finkelstein,  already  mentioned,  that  the  symp- 
toms are  due  to  intermediary  products  of  metabolism,  which  are  im- 
perfectly elaborated,  and  are  toxic.  He  regards  the  condition  as 
an  end  stage,  in  a  progressive  failure  of  nutrition. 

A  second  view  regards  the  symptoms  as  due  to  a  relative  acidosis. 
This  view  is  based  on  the  chemical  investigation  of  the  disease,  first 
undertaken  by  Czerny  and  Keller,  which  showed  that  in  children 
with  severe  watery  diarrhea  the  ammonia  content  of  the  urine  was 
much  increased.  No  abnormal  acids  could  be  found  to  account  for 
this,  and  the  acetone  bodies  are  not  usually  present  in  any  quantity 
in  the  urine.  Steinitz  first  showed  that  there  is  a  great  loss  of  bases, 
particularly  sodium,  by  the  alimentary  tract,  and  that  as  a  result 


Classification  of  the  Disturbances  of  Digestion        397 

of  this  a  relative  acidosis  occurs,  ammonia  being  produced  or  de- 
flected from  its  normal  role  in  forming  urea,  to  unite  in  the  urine 
with  the  acids  which  are  in  relative  excess  in  the  blood.  This  theory 
has  been  strengthened  by  some  recent  work  of  Rowland  and  Mar- 
riott, who,  investigating  toxic  cases  of  diarrhea,  especially  those  with 
dyspnea,  found  evidence  of  acidosis  as  shown  by  a  diminution  of  the 
carbon  dioxide  tension  of  the  alveolar  air.  They  confirmed  this 
evidence  by  investigations  of  the  acidity  of  the  blood  by  two  methods. 
They  also  found  in  these  cases  an  increased  tolerance  for  alkali, 
such  as  is  seen  in  other  forms  of  acidosis. 

The  third  view  regards  the  symptoms  as  due  to  the  absorption  from 
the  intestine  of  toxic  fermentation  products.  This  view  regards  abnor- 
mal bacterial  activity  as  the  primary  cause  of  the  diarrhea,  and  as 
the  chief  cause  of  the  symptoms. 

It  is  probable  that  all  three  theories  are  true.  The  toxic  condi- 
tion called  alimentary  intoxication,  is  undoubtedly  a  symptom-complex, 
not  a  disease  in  itself,  and  can  be  produced  in  various  ways,  by  various 
causes.  The  theory  of  a  relative  acidosis  does  not  concern  itself 
with  the  original  cause  which  produces  the  diarrhea,  but  applies 
only  to  the  manner  in  which  the  symptoms  are  produced.  A  rela- 
tive acidosis  is  a  result  of  a  disturbance  of  metabolism,  and  the  only 
question  is  whether  the  disturbance  leads  to  the  formation  of  toxic 
intermediary  products,  or  to  a  relative  excess  of  acid  through  loss 
of  alkali.  There  is  no  doubt  that  the  latter  can  occur,  that  in  cer- 
tain cases,  especially  those  characterized  by  dyspnea,  the  symp- 
toms are  a  manifestation  of  acidosis.  I  believe  that  in  cases  with 
severe  watery  diarrhea,  it  is  more  probable  that  the  symptoms  are 
produced  by  a  relative  acidosis  than  by  the  intermediary  products 
of  metabolism.  Such  cases  are,  however,  usually  acute.  Toxic 
symptoms  are  often  seen  in  cases  of  a  chronic  type,  occurring  toward 
the  end  of  a  long  history  of  nutritional  disturbance.  While  diarrhea 
occurs  in  these  chronic  cases,  it  is  not  so  severe  as  in  the  acute  ones. 
While  the  toxic  symptoms  in  this  type  also  may  be  due  to  a  relative 
acidosis,  I  believe  that  we  cannot  exclude  the  possibility  that  toxic 
intermediary  products  of  metabolism  may  also  be  a  cause. 

The  third  view,  that  the  symptoms  are  due  to  the  absorption  from 
the  intestine  of  the  toxic  products  of  abnormal  bacterial  activity, 
brings  into  sharp  contrast  two  distinct  forms  of  thought  as  to  gastro- 
intestinal disease  which  are  prevalent  among  the  pediatrists  of  this 
country.  One  might  be  termed  the  chemical  view-point,  which  re- 
gards all  the  functional  gastro-intestinal  diseases  such  as  are  classified 
here  as  disturbances  of  digestion,  as  chemical,  both  in  origin  and 
effects.  Chemical  food  injury,  and  the  resulting  chemical  disturb- 
ances of  metabolism  account  for  everything.  Bacterial  processes  are 
neglected.     The  other  view-point  might  be  called  the  bacteriological, 


398 


Diseases  of  the  Gastro-Enteric  Tract 


in  which  an  important  role  is  assigned  to  abnormal  bacterial 
fermentation. 

I  believe  that  both  views  are  made  too  exclusive  by  their  sup- 
porters, and  that  both  factors,  the  chemical  and  the  bacteriological, 
play  an  important  part.  I  believe  that  the  chemical  men  have  gone 
too  far  in  minimizing  the  importance  of  bacteria.  On  the  other  hand, 
we  in  Boston  have  always  been  inclined  toward  the  bacteriological 
view-point,  probably  also  too  exclusively. 

The  following  is  my  personal  opinion  as  to  the  condition  some- 
times described  as  alimentary  intoxication.  It  is  a  symptom-complex 
having  a  varied  etiology.  When  it  occurs  in  the  course  of  chronic 
forms  of  indigestion,  or  as  an  end  symptom  of  a  chronic  severe  nu- 
tritional disturbance,  it  is  to  be  explained  on  chemical  grounds. 
The  symptoms  are  produced  by  some  chemical  disturbance  of  meta- 
bolism, which  is  caused  by  some  form  of  relative  overfeeding  ("food 
injury").  The  chemical  disturbance  of  metabolism  which  produces 
the  symptoms  may  be  a  relative  acidosis,  especially  if  diarrhea  be 
prominent  and  severe,  or  it  may  be  a  break-down  of  the  intermediary 
metabolism  with  the  formation  of  toxic  products.  When  the  symp- 
tom-complex occurs  as  an  acute  manifestation,  occurring  most  often 
in  summer,  and  apparently  independent  of  relative  overfeeding,  it 
is  to  be  explained  on  bacteriological  grounds.  The  symptoms  may 
be  produced  either  by  the  absorption  of  the  toxic  products  of  fer- 
mentation, or  by  a  chemical  disturbance  of  metabohsm  caused  by 
the  diarrhea.  In  the  former  case,  the  toxins  are  probably  due  to 
the  activity  of  proteolytic  microorganisms.  In  the  latter  case,  the 
disturbance  of  metabolism  is  probably  due  to  the  loss  of  mineral 
salts  in  the  stools  which  occurs  in  severe  diarrhea,  and  is  a  relative 
acidosis.     This  view  is  explained  by  the  following  diagram: 


Chemical  Food  Injury. 
(In  chronic  cases.) 


Abnormal  Bacterial  Fermentation. 
(In  acute  cases.) 


[Disturbance  of 
j  Intermediary 
Metabolism 


\[ 


fFormation 

of 
Toxic  Products 


.  (Diarrhea.    Loss  of 
I  Alkaline  Bases 


fFormation  of 
I  Toxic  Products 
[in  intestine 


Relative 
Acidosis 


\  I  Intoxication 


(Absorption         1 
[Toxic  Products  J 


GENERAL  SYMPTOMATOLOGY.— The  principal  symptoms 
associated  with  disturbances  of  digestion  are  vomiting,  abnormal 
stools  or  diarrhea,  loss  of  weight,  and  at  times,  toxic  symptoms 
involving  the  nervous  system.  There  is  no  definite  grouping  of  the 
symptoms  associated  with  any  particular  etiologic  type  of  digestive 
disturbance. 


Diagnosis  of  the  Disturbances  of  Digestion  399 

DIAGNOSTIC  METHODS.— We  can  only  rely  to  a  limited 
extent  upon  the  grouping  of  the  clinical  symptoms  in  making  a 
diagnosis.  The  most  valuable  diagnostic  procedure  available  is  the 
examination  of  the  stools.  This  gives  very  valuable  information  at 
times,  as  to  which  food  element  in  excess  is  producing  the  symptoms. 
The  technique  of  this  examination  has  been  described  in  the  general 
section  on  diagnostic  methods. 

The  information  derived  from  the  examination  of  the  stools  is 
not  often  conclusive,  and  one  must  rely  on  some  other  means  of 
arri\dng  at  a  conclusion.  The  most  valuable  diagnostic  indication  is 
often  the  reaction  of  the  child  to  the  food  given.  We  cannot  always 
form  any  conclusion  as  to  this  point  when  we  first  see  a  case  of  dis- 
turbance of  digestion.  A  careful  history  of  the  case  should  always 
be  taken,  which  should  include  a  description  of  each  food  previously 
given  to  the  child,  and  of  all  the  symptoms  which  were  present  during 
the  period  of  its  administration.  Particular  inquiry  should  be  made 
as  to  vomiting,  its  frequency  and  character,  as  to  the  daily  number 
and  character  of  the  stools  passed,  as  to  loss  of  weight,  as  to  irrita- 
tion of  the  buttocks,  as  to  abdominal  distention.  In  order  to  form 
conclusions,  it  is  advisable  to  translate  each  food  given  into  the 
terms  of  its  composition  as  expressed  by  the  percentages  of  the 
various  food  elements.  In  this  way  we  can  know  just  how  much 
fat,  how  much  and  what  kind  of  carbohydrate  and  protein,  were 
given  with  each  food.  With  a  knowledge  of  the  composition  of 
each  food  given,  of  the  manner  of  its  giving,  and  of  the  symptoms 
which  attended  its  use,  we  can  often  form  preliminary  conclusions 
as  to  the  probable  type  of  indigestion  with  which  we  have  to  deal. 
We  then  start  our  treatment  on  the  basis  of  these  conclusions,  the 
first  food  which  we  order  being  considered  a  sort  of  trial  formula. 
From  this  time  on  we  must  be  guided  by  the  reaction  of  the  infant, 
as  shown  by  its  symptoms  and  weight  curve,  and  by  the  results  of 
frequent  examinations  of  the  stools. 

Although  abnormal  bacterial  fermentation  is  probably  the  cause 
of  the  symptoms  in  certain  cases,  yet  we  have  as  yet  no  bacteriological 
technique  by  which  such  processes  may  be  definitely  recognized.  Our 
diagnosis  here  must  rest  upon  the  clinical  picture,  and  upon  the 
results  of  treatment. 

GENERAL  PROGNOSIS.— The  prognosis  of  the  disturbances  of 
digestion  varies  with  the  type  of  indigestion  present,  and  with  the 
severity  of  the  case. 

GENERAL  TREATMENT.— The  general  principle  of  treatment 
in  the  disturbances  of  digestion  is  the  removal  of  the  cause.  The 
treatment  varies  somewhat  according  to  whether  the  disorder  is  of 
an  acute  or  of  a  chronic  character.     In  acute  cases,  we  try  first  to 


400  Diseases  of  the  Gastro-Enteric  Tract 

remove  from  the  gastro-intestinal  canal  the  offending  products  of 
indigestion.  This  is  effected  by  the  use  of  purgatives,  enemata,  or 
high  irrigation  of  the  colon.  We  then  rest  the  gastro-intestinal  canal, 
and  finally  begin  the  administration  of  a  food  which  we  beheve  the 
patient  can  digest  properly.  In  chronic  cases,  the  treatment  is 
mainly  dietetic  from  the  start,  supplemented  by  the  correction  of 
faulty  hygienic  surroundings.  The  complete  withdrawal  of  food  is 
not  advisable  in  the  treatment  of  chronic  cases.  In  feeble,  atrophied 
infants  even  temporary  starvation  may  be  highly  dangerous.  The 
methods  of  feeding  employed  vary  with  the  particular  type  of  case. 

Drugs  have  very  little  place  in  the  treatment  of  either  acute  or 
chronic  disturbances  of  digestion,  in  early  life.  The  so-called  "diges- 
tants,"  such  as  hydrochloric  acid,  preparations  of  pepsin,  or  pan- 
creatic extracts,  are  entirely  unnecessary.  Pepsin,  hydrochloric  acid, 
and  rennin  are  never  deficient  in  the  gastric  secretion,  and  the  pan- 
creatic ferments  are  destroyed  in  their  passage  through  the  stomach. 
The  only  medicinal  agents  of  frequent  value  are  the  purgatives,  the 
best  being  castor  oil  and  calomel.  Castor  oil  is  indicated  in  begin- 
ning the  treatment  of  all  acute  cases  with  diarrhea,  calomel  being 
substituted  if  the  oil  is  vomited.  Calomel  is  indicated  in  beginning 
the  treatment  of  acute  cases  in  which  vomiting  is  the  principal 
symptom. 

There  are  certain  symptoms  which  occur  in  several,  or  in  all 
forms  of  indigestion,  the  treatment  of  which  requires  a  brief  dis- 
cussion. 

Vomiting. — Calomel  in  divided  doses  should  be  given  at  the  onset 
of  an  acute  attack  of  vomiting.  If  the  vomiting  continues  after  the 
stomach  is  rested,  sodium  bicarbonate,  in  doses  of  2  grains  to  a  tea- 
spoonful  of  water,  will  sometimes  help. 

None  of  the  drugs  advocated  for  the  treatment  of  vomiting  in 
adults,  should  be  used  in  children.  Even  bismuth  should  not  be 
used.  Theoretically,  bismuth  acts  by  lessening  the  irritability  of  the 
gastric  mucosa.  In  children,  vomiting  is  Nature's  eft'ort  to  get  rid 
of  undesirable,  undigested  food.  Bismuth  usually  will  not  help  the 
vomiting,  and  if  it  does  help,  it  is  only  masking  a  symptom  which 
should  serve  as  a  guide  to  the  proper  dietetic  management  of  the  case. 

Vomiting,  when  chronic,  is  best  treated  by  changes  in  the  compo- 
sition of  the  food.  Sometimes,  however,  as  a  result  of  prolonged 
irritation  from  some  form  of  indigestion,  the  stomach  becomes  so 
irritable  that  it  rejects  the  food  even  after  the  cause  of  indigestion 
has  been  removed.  Even  in  cases  of  this  kind,  all  medicinal  treat- 
ment is  usually  totally  ineffective.  The  best  measure  which  can  be 
employed,  especially  in  an  infant,  is  daily  gastric  lavage.  When 
vomiting  is  so  severe  that  the  child  is  threatened  with  starvation, 


General  Treatment  of  Disturbance  of  Digestion       401 

rectal  feeding  should  be  instituted,  and  the  irritable  stomach  should 
be  given  a  prolonged  rest.  Feeding  through  the  duodenal  catheter 
is  a  very  valuable  resource  in  some  cases. 

DiARRHEA,^ — -The  diarrhea  caused  by  the  various  forms  of  indi- 
gestion is  an  effort  on  the  part  of  Nature  to  rid  the  body  of  offending 
material.  Consequently,  all  measures  aimed  at  checking  the  diar- 
rhea are  contraindicated.  The  treatment  is  that  of  the  cause,  and 
varies  with  the  cause.  The  drugs  particularly  to  be  avoided  are 
the  astringents  and  the  opiates. 

I  have  entirely  given  up  the  use  of  bismuth  in  the  diarrhea  caused 
by  any  form  of  indigestion.  A  prolonged  investigation  of  the  results 
of  the  routine  use  of  bismuth,  extending  through  eight  years'  summer 
service  at  the  Infants'  Hospital  Outpatient  Clinic,  has  convinced  me 
that  bismuth  is  of  no  value  in  lowering  the  mortality,  lessening  the 
severity  of  the-  diarrhea,  or  shortening  its  duration.  There  were 
individual  cases  which  appeared  to  improve  under  bismuth,  but  the 
statistics  as  a  whole  showed  no  favorable  action,  and  it  is  probable 
that  the  apparent  improvement  was  an  instance  of  coincidence  rather 
than  of  cause  and  effect.  There  was,  however,  no  evidence  that 
bismuth  does  any  harm. 

The  injury  to  the  body  caused  by  diarrhea  comes  from  three 
things,  I,  loss  of  fluid,  2,  loss  of  food  elements,  3,  irritating  or  toxic 
products  of  the  indigestion.  The  checking  of  diarrhea  may  dimin- 
ish the  first  two  causes  of  injury,  but  will  dangerously  increase  the 
third.  The  loss  of  fluid  can  be  made  up  by  the  giving  of  fluid  by 
rectum,  subcutaneously,  or  intravenously.  The  loss  of  food  elements 
can  be  made  up  by  careful  regulation  of  the  diet. 

Colic. — This  is  really  the  only  symptom  requiring  special  treat- 
ment in  infants.  It  will  be  relieved  by  removal  of  the  cause,  but 
often  the  relief  is  not  immediate.  Also  when  nutrition  is  progressing 
favorably,  and  colic  is  the  only  symptom  of  indigestion,  it  is  often 
better  to  treat  the  colic  symptomatically,  and  not  to  change  the 
composition  of  the  food. 

For  colic  the  most  effective  measure  is  to  give  the  baby  a  quarter 
or  a  half  of  a  soda  mint  tablet  dissolved  in  a  tablespoonful  of  hot 
water.  Hot  applications  to  the  abdomen  will  often  help.  If  these 
measures  are  not  effective,  the  physician  may  try  a  few  drops  of 
essence  of  peppermint,  or  of  brandy,  in  the  same  amount  of  hot 
water.  If  this  fails,  and  if  the  attack  is  severe,  an  enema  should 
be  given.  Only  in  the  most  severe  and  resistant  cases  is  it  ever 
necessary  to  resort  to  a  few  drops  of  paregoric. 

Colic  is  sometimes  due  to  the  swallowing  of  air  during  nursing. 
The  symptoms  can  be  prevented  if  from  time  to  time  during  nursing 
the  baby  is  held  upright  and  patted  on  the  back  until  the  swallowed 
air  escapes. 

26 


402  Diseases  or  the  Gastro-Enteric  Tract 

INDIGESTION  FROM  AN  EXCESS  OF  FOOD 

ETIOLOGY. — This  condition  occurs  when  the  food  given  to  an 
infant  or  child  is  too  much  for  its  digestive  power.  The  food  may 
be  either  excessive  in  quantity,  or  too  rich  in  quaHty.  The  dis- 
turbance may  be  acute  or  chronic. 

Acute  Ikdigestion  from  overfeeding  occurs  when  there  is  a  sud- 
den disturbance  in  the  balance  between  the  digestive  power  and 
the  food.  Such  a  condition  can  occur  either  from  some  sudden 
change  in  the  quantity  or  composition  of  the  food,  or  from  some 
sudden  lowering  of  the  digestive  power  without  change  in  the  food. 

In  breast-fed  babies  the  various  etiological  factors  influencing 
lactation,  such  as  disease  or  emotional  excitement,  may  cause  a 
sudden  change  in  the  composition  of  the  breast  milk,  which  occasion- 
ally may  be  enough  to  cause  indigestion.  In  artificially  fed  babies 
a  change  of  milk  supply,  or  of  the  composition  of  the  food,  may 
similarly  cause  indigestion.  Under  indigestion  from  excess  of  food 
must  also  be  grouped  those  cases  in  older  children  produced  by 
overeating — "overloading  the  stomach,"  as  it  is  sometimes  called, — 
and  by  the  eating  of  some  particular  article  of  diet,  such  as  pickles, 
cucumbers,  hot  bread,  cake,  rich  fried  things,  which  is  unsuited  to 
the  digestive  power  of  a  child  of  that  age.  Similar  articles,  un- 
suited to  the  digestive  power,  are  sometimes  given  even  to  babies. 
Many  cases  of  acute  indigestion  have  been  produced  by  giving  to 
babies  "a  httle  taste"  of  some  article  of  diet  from  the  adult  table, 
such  as  a  bite  of  banana,  a  bit  of  candy,  or  a  little  piece  of  cake. 

Acute  indigestion  is  not  always  produced  by  some  dietetic  out- 
rage. There  may  be  no  indiscretion  in  the  food  given  to  a  child, 
and  yet  a  sudden  disturbance  of  digestion  may  occur.  In  such  cases 
the  indigestion  results  from  a  relative  excess  of  food,  and  the  imme- 
diate cause  must  be  looked  for  among  those  etiological  factors  which 
produce  a  sudden  lowering  of  the  digestive  power.  Among  the 
commonest  are  heat,  cold,  emotional  excitement,  fatigue,  and  disease. 
Heat,  or  sudden  changes  of  temperature  in  hot  weather,  are  the 
commonest  of  these  causes.  Many  of  the  cases  of  acute  diarrhea 
of  the  milder  type,  occurring  in  the  summer  months,  are  produced 
in  this  way,  and  even  in  breast-fed  babies  these  mild  acute  disturb- 
ances are  comparatively  common. 

Chronic  Indigestion  from  an  excess  of  food  occurs  when  there 
is  a  continual  disturbance  of  the  relation  between  the  food  and  the 
digestive  power.  The  food  may  be  too  great  in  amount,  may  be 
too  rich,  or  may  be  given  too  frequently.  The  condition  is  uncom- 
mon in  breast-fed  infants.  It  is  more  common  in  the  artificially  fed, 
but  nevertheless,  chronic  indigestion  from  overfeeding  as  a  whole 
is  infinitely  less  common  than  is  chronic  indigestion  from  an  exces- 


Indigestion  from  an  Excess  of  Food  403 

sive  amount  of  one  or  more  of  the  individual  food  elements.  It 
would  seem  that  in  chronic  indigestion,  even  if  originally  produced 
simply  by  an  excess  of  food,  the  digestive  power  soon  begins  to  dis- 
tinguish amongst  the  various  food  elements,  and  to  show  more  marked 
intolerance  toward  certain  ones. 

SYMPTOMS.  Acute  Indigestion. — In  acute  indigestion  caused 
by  a  relative  excess  of  food,  there  are  two  common  clinical  t}^es, 
one  characterized  by  vomiting,  the  other  by  diarrhea. 

In  the  first  type  there  is  a  sudden  attack  of  vomiting.  The  vom- 
itus  is  not  characteristic;  in  infants  it  is  usually  sour,  and  contains 
curds.  When  the  attack  is  caused  by  some  improper  article  of  diet, 
this  appears  in  the  vomitus.  If  the  case  is  not  properly  treated, 
and  the  vomiting  continues,  the  vomitus  may  contain  bile.  The 
vomiting  is  not  repeated  more  than  a  few  times,  unless  feeding  is 
continued.  Water  is  usually  not  vomited.  The  failure  to  with- 
hold food,  especially  if  food  be  given  soon  after  vomiting,  may  cause 
the  symptoms  to  be  continued  indefinitely,  so  that  all  food,  and 
sometimes  even  water,  may  be  vomited.  The  vomiting  is  accom- 
panied by  nausea,  and  is  often  preceded  by  eructations  of  gas,  and 
a  general  appearance  of  discomfort.  There  is  no  elevation  of  tem- 
perature, no  constitutional  disturbance,  and  no  other  important 
symptoms.  The  stools  are  not  characteristic.  In  some  cases  there 
may  be  an  accompanying  diarrhea,  but  this  is  not  common. 

In  the  second  type  there  is  an  acute  attack  of  diarrhea.  The 
movements  are  loose,  rather  large  in  amount,  and  vary  in  number 
from  six  to  twelve  in  the  twenty-four  hours,  and  are  usually  free 
from  much  odor.  They  are  not  characteristic  but  may  show  evi- 
dences of  indigestion  of  any  or  all  of  the  food  elements.  Their  color 
is  a  mixture  of  yellow,  brown,  and  white,  and  they  have  a  generally 
undigested  appearance.  They  may  contain  some  recognizable  im- 
proper article  of  diet,  entirely  undigested.  There  may  also  be  a 
light  greenish  color,  but  the  deeper  shades  of  green  are  not  often 
seen.  The  stools  may  be  either  acid  or  alkaline  in  reaction.  There 
may  be  a  small  amount  of  mucus,  but  blood  is  seldom  present, 
except  in  cases  in  which  the  attack  has  lasted  a  long  time.  It  may 
be  present  in  rare  cases  in  which  some  particularly  irritating  article 
of  diet  has  been  taken.  Abdominal  pain  and  vomiting  may  or  may 
not  be  present,  usually  not.  The  temperature  as  a  rule  is  normal 
or  only  shghtly  raised,  and  the  slight  fever  sometimes  seen  is  of 
brief  duration.  As  a  rule,  there  is  moderate  loss  of  weight.  The 
duration  of  the  attack  depends  on  the  treatment,  and  may  be  much 
prolonged  by  continued  giving  of  a  relative  excess  of  food. 

Chronic  Indigestion. — The  symptoms  of  chronic  disturbance  of 
the  balance  between  the  food  and  the  digestive  power  are  vomiting. 


404  Diseases  or  the  Gastro-Enteric  Tract 

an  increased  number  of  stools,  loss  of  appetite,  colic,  eructations 
of  gas,  and  a  failure  to  gain  in  weight,  or  a  moderate  loss.  The 
vomiting  is  usually  not  seen  after  every  feeding.  The  vomitus  and 
stools  are  not  characteristic,  and  may  show  evidences  of  indigestion 
of  any  or  all  of  the  food  elements.  When  vomiting  is  the  most 
pronounced  symptom,  the  bowels  may  be  constipated.  The  babies 
are  often  fussy  and  do  not  sleep  well,  but  fever  and  constitutional 
disturbance  are  absent. 

DIAGNOSIS. — The  acute  type  with  vomiting  must  be  distin- 
guished from  vomiting  as  a  symptom  of  disease  elsewhere,  and  from 
recurrent  vomiting.  Most  of  the  diseases  having  acute  vomiting  as 
a  symptom  are  acute  infections,  and  can  be  excluded  by  the  absence 
of  fever  and  other  physical  signs.  Tuberculous  meningitis  sometimes 
begins  with  vomiting,  before  fever  or  any  characteristic  symptoms 
are  present.  It  is  distinguished  from  acute  indigestion  by  failure 
to  react  promptly  to  treatment.  Recurrent  vomiting  is  character- 
ized by  the  facts  that  no  dietetic  cause  is  ever  discoverable,  that 
there  has  often  been  a  previous  similar  attack,  that  the  vomiting 
usually  continues  to  occur  when  only  water  or  even  no  food  at  all 
are  given,  and  that  the  urine  always  shows  a  strongly  positive  reac- 
tion for  acetone  even  at  the  beginning  of  the  attack. 

The  acute  type  with  diarrhea  must  be  distinguished  from  other 
conditions  in  which  acute  diarrhea  is  or  may  be  the  most  prominent 
symptom.  The  most  common  are  nervous  diarrhea,  acute  indi- 
gestion with  fermentation,  and  infectious  diarrhea.  Nervous,  diar- 
rhea is  excluded  by  means  of  the  character  of  the  stools,  which 
in  indigestion  always  show  some  abnormality  suggesting  disturbed 
digestion,  but  which  in  nervous  diarrhea  are  loose  but  otherwise 
normal  in  appearance.  The  distinction  between  the  acute  diarrhea 
of  indigestion  from  relative  overfeeding,  and  the  acute  diarrhea  of 
fermentation,  is  often  very  difficult,  because  a  sharp  line  cannot  be 
drawn  between  the  two  conditions.  It  is  probable  that  all  but  the 
mildest  cases  of  simple  indigestion  are  accompanied  by  a  certain 
amount  of  abnormal  bacterial  fermentation  in  the  intestinal  con- 
tents. The  symptoms  of  the  two  conditions  are  very  similar.  The 
distinction  has  to  be  a  very  arbitrary  one,  based  mainly  on  the  greater 
severity  of  the  symptoms  in  acute  indigestion  with  fermentation. 
The  presence  of  fever,  constitutional  symptoms,  or  other  evidences 
of  toxemia,  would  lead  the  case  to  be  regarded  as  one  of  fermenta- 
tion. If  these  symptoms  are  absent,  very  frequent  green  or  watery 
stools,  possibly  showing  a  frothy  appearance  characteristic  of  exces- 
sive fermentation,  or  having  a  very  foul  odor,  would  also  suggest  a 
process  more  severe  than  simple  indigestion.  In  infectious  diarrhea 
there  is  persistent  fever,  and  the  stools  show  the  early  appearance 


Indigestion  from  an  Excess  of  Food  405 

of  excessive  mucus,  or  of  mucus  and  blood,  while  in  simple  indiges- 
tion there  is  no  persistent  fever,  and  excessive  mucus  or  blood  are 
uncommon  signs,  appearing  late  in  the  course  of  the  disease. 

The  chronic  type  of  indigestion  from  an  excess  of  food  is  distin- 
guished from  the  chronic  types  due  to  indigestion  from  the  various 
elements,  by  the  comparative  mildness  of  the  symptoms,  the  absence 
of  characteristic  stools,  the  absence  of  a  reaction  to  feeding  showing 
intolerance  for  a  particular  food  element,  and  the  ready  response  to 
treatment. 

PROGNOSIS. — The  prognosis  of  indigestion  due  to  relative  over- 
feeding is  usually  good.  In  the  type  characterized  by  acute  diar- 
rhea, the  disease  may  pass  over  into  the  type  due  to  excessive  bac- 
terial fermentation,  or  even  into  infectious  diarrhea.  Usually, 
however,  it  yields  readily  to  proper  treatment,  as  do  the  acute  vomit- 
ing and  chronic  types. 

TREATMENT.  Acute  Indigestion.— The  essentials  of  treat- 
ment are,  to  empty  the  gastro-  ntestinal  canal  of  undigested  residue, 
to  rest  it,  and  then  to  give  a  food  which  shall  be  within  the  child's 
power  of  digestion.  In  the  type  characterized  by  vomiting,  calomel 
should  be  given,  in  small  divided  doses.  Calomel  is  preferable  to 
castor  oil  whenever  there  is  much  vomiting,  because  it  not  only 
empties  the  intestine,  but  in  divided  doses  tends  to  overcome  the 
tendency  to  reversed  peristalsis  in  the  stomach  which  is  causing  the 
vomiting  to  continue.  It  tends  to  start  peristalsis  in  the  right  direc- 
tion throughout  the  gastro-intestinal  canal.  One-tenth  of  a  grain 
may  be  given  every  half-hour,  for  five  doses  to  a  baby  under  six 
months,  and  for  ten  doses  to  a  baby  between  six  months  and  three 
years ;  one-quarter  of  a  grain  every  half -hour  for  eight  doses  may 
be  given  to  older  children.  The  calomel  need  not  be  followed  by 
a  cathartic,  if  the  bowels  move. 

In  the  type  characterized  by  diarrhea,  castor  oil  is  preferable  to 
calomel.  One  teaspoonful  may  be  given  to  an  infant  in  the  first 
year,  and  two  to  an  infant  in  the  second  year. 

From  the  time  the  calomel  is  started  or  the  castor  oil  is  given,  no 
food  should  be  allowed  for  a  certain  period,  although  water  can  be 
given.  In  vomiting  cases,  and  in  breast-fed  babies  with  diarrhea, 
food  should  be  withheld  for  the  next  two  to  four  feedings,  varying 
with  the  severity  of  the  case.  In  artificially  fed  babies  with  diar- 
rhea, food  should  be  withheld  for  at  least  twelve  hours.  Boiled 
water  should  be  given  at  the  regular  feeding  time.  In  older  children, 
with  vomiting,  only  the  next  meal  should  be  wholly  omitted,  but  if 
there  is  diarrhea,  it  is  safer  to  withhold  food  for  twelve  hours. 

When  feeding  is  resumed,  the  quantity  of  food  given  should  at 
first  be  far  below  the  normal.     In  breast-fed  infants,  the  breast  may 


406  Diseases  of  the  Gastro-Enteric  Tract 

be  given  for  five  minutes  at  the  first  feeding,  for  ten  minutes  at  the 
second,  and  for  fifteen  minutes  at  the  third.  The  breast  milk  should 
be  diluted  by  the  giving  of  two  teaspoonfuls  each  of  boiled  water 
and  lime  water  immediately  before  each  nursing.  This  should  be 
continued  for  some  time  if  there  is  reason  to  believe  the  attack  was 
caused  by  a  change  in  the  character  of  the  milk,  and  then  gradually 
omitted,  unless  symptoms  recur. 

In  artificially  fed  infants,  who  have  been  previously  doing  well, 
the  food  should  be  diluted  with  boiled  water  and  a  little  lime  water. 
In  diarrheal  cases,  a  one-quarter  dilution  should  be  given  the  first 
day,  a  one-half  dilution  the  second,  a  three-quarters  dilution  the 
third,  and  full  strength  the  fourth,  unless  symptoms  tend  to  recur, 
when  one  must  proceed  more  slowly.  It  is  well  to  boil  the  milk  for 
the  first  few  days.  In  vomiting  cases,  the  strength  of  the  food  may 
be  increased  more  rapidly,  if  no  vomiting  recurs. 

In  older  children,  feeding  may  be  begun  with  boiled  milk  diluted 
with  barley  water,  which  is  increased  in  the  same  way,  and  then  other 
articles  are  gradually  added  to  the  diet. 

If  in  an  acute  case,  vomiting  continues,  the  physician  should  try 
giving  sodium  bicarbonate  gr.  ii  in  a  teaspoonful  of  water  five  minutes 
before  each  feeding.  If  diarrhea  continues,  the  whole  treatment  must 
be  repeated,  with  a  longer  period  of  withholding  food,  a  weaker  food 
at  the  resumption  of  feeding,  and  a  slower  increase.  In  my  experi- 
ence, bismuth  is  of  no  value  in  diarrhea  of  this  type.  Astringents 
and  opiates  are  positively  contraindicated. 

Chronic  Indigestion. — In  chronic  cases,  and  in  acute  cases  which 
have  shown  any  symptoms  of  indigestion  before  the  acute  attack, 
no  cathartic  is  necessary,  but  a  new  dietary  must  be  given.  If  the 
quantity  of  food  is  excessive,  it  must  be  cut  down.  If  the  quantity 
is  not  excessive,  the  food  must  be  weakened.  It  is  best  to  bring  the 
strength  considerably  below  that  which  would  be  suitable  for  an 
average  normal  baby  of  the  same  age.  The  food  must  be  reduced 
in  strength  until  the  baby  is  free  of  symptoms;  then,  if  the  gain  in 
weight  is  not  satisfactory,  it  must  be  gradually  strengthened.  If 
symptoms  recur  before  a  proper  gain  in  weight  is  attained,  it  is 
probable  that  there  is  intolerance  of  some  particular  food  element, 
and  the  physician  must  determine  the  t>'pe,  by  increasing  the  food 
elements  separately. 

In  older  children,  cases  of  simple  indigestion  from  an  excess  of 
food  will  usually  do  well  when  the  dietary  errors  which  have  caused 
the  condition,  are  corrected. 


Indigestion  from  an  Excess  of  Fat  407 

INDIGESTION  FROM  AN  EXCESS  OF  FAT 

DIGESTION  AND  METABOLISM  OF  FAT.— The  disturbances 
due  to  a  quantity  of  fat  in  the  food  too  great  for  the  child  to  prop- 
erly carry  out  its  digestion  and  absorption,  involve  the  entire  meta- 
bolism. It  is  necessary,  therefore,  in  order  to  understand  this  form 
of  indigestion,  to  know  something  of  the  normal  digestion  and  meta- 
bolism of  fat,  and  of  the  effects  of  a  relative  excess.  The  subject  of 
infantile  metabolism  is  one  of  the  most  complicated  in  the  whole 
domain  of  pediatrics,  and  one  on  which  much  scientific  research  work 
is  being  at  present  carried  on.  The  recent  literature  of  the  subject 
is  enormous,  and  while  many  facts  of  varying  value  have  been  added 
to  our  knowledge,  the  problems  involved  still  remain  very  obscure. 
A  review  attempting  to  cover  what  is  known  of  the  digestion  and 
metabolism  of  fat,  would  take  up  too  much  space  for  a  general  work 
on  pediatrics.  Only  the  very  briefest  summary  of  the  facts  most 
essential  to  the  reader  will  be  attempted. 

Importance  of  Fat. — Fat  is  a  food  element  of  the  greatest  im- 
portance to  the  infant  on  account  of  its  high  caloric  value.  It  is 
used  as  a  source  of  energy — a  fuel,  and  it  is  difficult,  in  the  feeding 
of  an  infant,  to  make  up  for  a  deficiency  of  fat  by  increasing  the 
carbohydrate  and  protein  in  the  food.  There  are  wide  variations 
in  the  tolerance  for  cow's  milk  fat. 

Digestion  of  Fat.— While  there  is  a  gastric  fat-spHtting  ferment 
in  the  infant,  it  is  probably  of  very  little  importance  in  digestion. 
The  principal  digestion  of  fat  is  carried  out  in  the  intestine,  the 
processes  being  the  same  as  in  the  adult.  The  fat  is  subdivided  by 
the  alkaline  salts  of  the  intestinal  secretions,  and  split  by  the  fat- 
splitting  ferments.  As  a  result  fatty  acids  are  formed,  which  com- 
bine with  the  alkaline  carbonates  to  form  soaps.  In  the  presence 
of  these  soaps,  the  fat  is  subdivided  into  still  smaller  particles. 
Nearly  all  of  the  fat  in  the  food  is  split,  and  the  weight  of  evidence 
suggests  that  neutral  fat  cannot  be  absorbed,  and  that  splitting  is 
a  necessary  preliminary  to  absorption. 

Absorption  of  Fat. — The  form  in  which  the  fat  is  finally  ab- 
sorbed is  not  definitely  known.  There  is  much  difference  of  opinion 
as  to  whether  the  fat  is  absorbed  as  fatty  acids,  as  soluble  soaps,  or 
as  insoluble  soaps.  The  fat  enters  the  blood  stream,  where  it  has 
been  demonstrated  by  the  ultramicroscope. 

In  health,  with  a  normally  arranged  diet,  in  babies  of  normal 
digestive  power,  the  absorption  of  fat  is  extremely  good.  It  is  prac- 
tically as  good  in  babies  fed  on  cow's  milk  as  in  babies  fed  on  human 
milk,  and  the  amount  absorbed  is  usually  over  90%,  and  may  be 
as  great  as  98%.  The  absorption  of  fat  is  lessened  in  infants  with 
soap  stools,  and  there  is  a  still  greater  loss  of  fat  in  the  stools  of 


408  Diseases  of  the  Gastro-Enteric  Tract 

babies  having  a  diarrhea,  whether  such  a  diarrhea  is  caused  by 
excessive  fat,  or  by  some  other  form  of  indigestion,  such  as  that 
from  excessive  carbohydrate. 

Fat  in  the  Stools. — Fat  is  normally  present  in  the  stools,  in  the 
form  of  soaps.  Practically  all  of  this  fat  comes  from  the  food,  not 
from  the  intestinal  secretions.  The  amount  of  fat  normally  present 
in  the  stools  is  very  variable.  In  the  first  few  days  of  life  it  is  very 
large,  as  much  as  50%  of  the  dried  stool,  and  it  gradually  diminishes 
as  the  babies  grow  older.  The  usual  amount  in  later  infancy  lies 
between  14  and  25%,  although  it  has  been  found  as  high  as'  42% 
in  babies  apparently  normal.  Microscopic  examinations  of  the 
stools  for  fat  consequently  have  little  value  in  showing  excess  in 
the  early  weeks  of  life,  but  in  later  infancy,  they  have  more  value. 

Efeect  of  Excessive  Fat. — When  the  amount  of  fat  in  the  food 
is  in  relative  excess,  either  from  an  excessive  amount  of  fat  and 
normal  digestion,  or  from  a  normal  amount  of  fat  and  diminished 
powers  of  digestion,  there  may  be  an  effect  on  gastric  function.  It 
has  been  shown  that  an  excess  of  fat  has  a  direct  effect  on  the  empty- 
ing-time of  the  stomach,  retarding  it,  and  leading  to  gastric  stagna- 
tion, or  at  times  even  to  selective  retention  of  fat.  An  excess  of  fat 
also  delays  the  secretion  of  hydrochloric  acid  and  consequently  re- 
tards the  occurrence  of  the  pyloric  opening  reflex,  and  the  closure  of 
the  cardiac  orifice.  Regurgitation  or  vomiting  would  naturally 
result  from  this  action. 

In  the  intestine,  the  eff'ects  of  excessive  fat  depend  on  various 
factors,  among  them  being  the  relative  amounts  of  casein  and  carbo- 
hydrate in  the  food,  which  influence  the  intestinal  flora.  When  the 
casein  is  in  relative  excess,  the  prevalent  bacteria  belong  to  the 
putrefactive  group,  and  the  result  of  protein  decomposition  is  that 
the  intestinal  contents  remain  alkaline.  Under  these  conditions, 
the  fatty  acids  formed  from  the  splitting  of  the  neutral  fat  combine 
with  the  earthy  alkahes  to  form  the  so-called  "soap  stools,"  and 
calcium  and  magnesium  are  lost  from  the  organism.  When  the  car- 
bohydrate is  in  relative  excess,  the  acid-forming  bacteria  predominate, 
the  stools  are  acid,  and  the  fat  combines  with  sodium  and  potassium, 
forming  soft,  fatty  curds. 

The  interference  with  fat  absorption  when  ''soap  stools"  are 
formed,  and  the  consequent  disturbance  of  metabolism,  is  com- 
paratively slight,  and  may  or  may  not  be  suiflcient  to  cause  a  failure 
to  gain,  or  a  loss,  in  weight.  (C/.  Finkelstein's  Bilanzstorung.) 
When  soft,  fatty  curds  are  present,  with  loss  of  sodium  and  potas- 
sium, the  interference  with  absorption,  and  the  consequent  disturb- 
ance of  metabolism  are  probably  greater,  and  loss  of  body  weight 
usually  results.     (C/.  Finkelstein's  Dyspepsie.) 


Indigestion  from  an  Excess  of  Fat  409 

In  diarrhea  there  is  much  loss  of  fat  in  the  stools,  and  a  type 
sometimes  seen  is  characterized  by  acid  stools.  There  is  a  question 
whether  such  a  diarrhea  results  from  the  irritation  of  an  excessive 
amount  of  the  lower  fatty  acids  in  the  intestine — a  fatty  diarrhea 
from  primary  fat  indigestion — or  whether  the  diarrhea  is  caused  by 
some  other  form  of  indigestion,  such  as  that  from  carbohydrate, 
in  which  there  is  increased  peristalsis  and  loss  of  fat.  Probably 
both  conditions  can  occur.  In  this  condition  there  is  much  disturb- 
ance of  metabolism,  the  tissues  of  the  body  are  drawn  upon  to  fur- 
nish the  needed  fuel,  and  loss  of  weight  is  rapid.  (C/.  Finkelstein's 
Dekomposition.)  The  loss  of  alkaline  salts,  especially  sodium,  may 
be  so  great  as  to  cause  a  relative  acidosis,  with  an  excess  of  ammonia 
in  the  urine. 

In  the  extreme  condition  of  malnutrition  known  as  infantile  atro- 
phy, or  marasmus,  there  are  usually  evidences  of  diminished  power 
of  digesting  and  absorbing  fat,  as  is  evidenced  by  the  voluminous 
literature  of  the  metabolism  of  this  condition.  Metabolism  experi- 
ments cannot  prove  definitely,  however,  whether  infantile  atrophy 
is  the  cause  or  the  effect  of  diminished  power  of  digesting  and  ab- 
sorbing fat.  It  seems  very  probable  that  in  most  cases  it  is  an 
■effect  rather  than  a  cause. 

Toxic  symptoms  may  develop  in  the  course  of  fat  indigestion. 
(C/.  Finkelstein's  Intoxication.)  It  is  not  established  whether  they 
are  due  to  the  relative  acidosis  sometimes  present,  or  to  the  toxic 
products  of  an  extremely  disordered  metabolism.  They  are  prob- 
ably not  due  to  absorption  of  lactose,  as  was  originally  suggested 
by  Finkelstein. 

ETIOLOGY. — With  all  the  known  facts  about  the  results  of  a 
relative  overfeeding  with  fat,  the  first  cause  of  a  diminished  power 
to  digest  and  absorb  fat  is  not  definitely  known.  Of  course,  in  cases 
grossly  over-fed  with  fat,  the  cause  of  the  symptoms  is  clear,  but 
in  cases  in  which  there  is  present  a  diminished  power  of  digesting 
and  absorbing  comparatively  small  amounts  of  fat,  the  question 
arises,  what  is  the  first  cause  of  this  diminished  power.  We  know 
that  in  the  normal  baby  the  power  of  taking  care  of  cow's  milk  fat 
is  good.  Yet  cases  of  fat  intolerance  are  seen  mainly — almost  en- 
tirely— in  artificially  fed  babies.  The  question  is  unsettled.  There 
are  various  theories.  One  is  that  the  first  injury  comes  from  the 
chemical  composition  of  the  fats  in  cow's  milk,  which  differs  some- 
what from  that  of  the  fats  in  human  milk.  Another  is  that  it  is 
the  different  salt  content  of  cow's  milk  which  causes  the  first  trouble. 
Still  another  is  that  the  first  injury  to  digestion  and  metabolism 
comes  from  an  excess  of  carbohydrate,  and  that  this  injury  lessens 
the  power  of  digesting  and  absorbing  fat. 


410  Diseases  of  the  Gastro-Enteric  Tract 

In  any  case,  whatever  the  first  cause,  the  condition  with  which 
we  are  confronted  is  an  intolerance  toward  fat. 

SYMPTOMS.  Clinical  Types  in  Artificially  Fed  Infants. — 
The  majority  of  cases  of  fat  indigestion  occur  in  artificially  fed  in- 
fants, and  therefore  the  symptoms  seen  in  babies  fed  on  cow's  milk 
will  be  described  first.  In  the  previous  history  there  is  often  a  long 
story  of  various  symptoms  attending  various  attempts  at  feeding 
with  artificial  food.  Sometimes  indigestion  from  fat  is  seen  in  very 
young  babies;  these  are  cases  which  either  are  grossly  overfed  with 
fat,  or  which  have  a  marked  individual  intolerance  toward  fat.  More 
often,  indigestion  from  fat  is  met  with  in  babies  who  are  somewhat 
older,  and  who  have  a  history  of  previous  gastro-enteric  disturbance. 
This  previous  history  may  or  may  not  suggest  that  fat  was  the  cause 
of  the  trouble.  Often  there  is  a  previous  history  of  gross  overfeeding 
with  carbohydrate,  and  symptoms  of  carbohydrate  indigestion. 

The  three  principal  symptoms  of  fat  indigestion  are  vomiting, 
abnormal  stools,  and  failure  to  gain  in  weight  or,  more  often,  progres- 
sive loss.  There  may  also  be  flatulence,  colic,  and  loss  of  appetite. 
There  may  be  slight  irregular  fever,  or  occasional  rises  of  tempera- 
ture. The  condition  is  essentially  a  chronic  one.  Acute  symptoms 
may  arise  in  the  course  of  a  case  of  indigestion  from  fat,  but  are 
obviously  an  acute  exacerbation  in  a  case  which  has  shown  symp- 
toms of  chronic  disturbance  of  digestion  for  some  time. 

There  are  four  important  clinical  types  in  indigestion  from  fat. 
These  types  are  characterized  respectively  by  i,  vomiting,  2,  soap 
stools,  3,  stools  containing  soft,  fatty  curds,  and  4,  loose,  green  stools. 

In  the  first  type,  vomiting  is  the  principal  symptom.  It  represents 
the  effect  of  excessive  fat  in  causing  delayed  emptying  time  of  the 
stomach  with  a  selective  retention  of  fat.  The  vomiting  does  not 
occur  immediately  after  feeding,  except  sometimes  in  long-standing 
cases,  but  occurs  in  the  middle  or  toward  the  end  of  the  interval 
between  feedings.  The  vomitus  is  acid  in  reaction,  and  has  a  strongly 
sour  odor  due  to  the  presence  of  butyric  and  other  fatty  acids.  It 
usually  contains  small,  flaky  curds.  The  stools  in  this  type  are  not 
characteristic  macroscopically,  and  on  micro-chemical  examination 
do  not  regularly  show  the  presence  of  an  excessive  quantity  of  fat. 
The  frequent  failure  of  the  stools  to  show  evidences  of  excessive 
fat  is  due  to  the  fact  that  the  excess  is  vomited  and  does  not  pass 
through  the  intestine.  Vomiting  may  occur  occasionally  in  the 
other  chnical  types,  but  in  this  first  type,  vomiting  is  practically 
the  only  symptom,  except,  of  course,  the  loss  of  weight. 

In  the  second  type,  the  clinical  appearances  of  indigestion  are  not 
very  marked,  so  that,  unless  particular  notice  be  taken  of  the  char- 
acter of  the  stools,  it  seems  difiicult  to  account  for  the  failure  of  the 


Indigestion  from  an  Excess  of  Fat  411 

infant  to  gain  in  weight.  The  stools  macroscopically  appear  well 
digested,  and  are  not  loose.  In  color  they  are  usually  white,  gray, 
or  grayish-yellow,  and  in  size  and  consistency  they  are  large,  hard, 
and  dry.  They  may  have  a  glistening  appearance  when  mechanically 
spread  upon  the  napkin.  The  appearance  of  the  stools  in  this  type 
is  sometimes  suggestive,  but  often  does  not  differ  sufficiently  from 
that  seen  in  babies  who  are  doing  well  to  be  diagnostic.  They  rep- 
resent the  "soap  stools,"  in  which  the  fat  is  in  combination  with 
calcium  and  magnesium.  Microscopically,  the  stools  show  an  ex- 
cessive amount  of  fat  in  the  form  of  soap.  Loss  of  weight  is  usually 
slight  in  this  type,  and  there  may  only  be  failure  to  gain. 

In  the  third  type,  the  most  common  in  severe  cases,  the  stools 
contain  many  small,  soft  curds.  They  may  contain  considerable 
mucus  also.  These  stools  represent  the  type  in  which  the  fatty 
acids  have  combined  with  sodium  and  potassium.  Sometimes  the 
fatty  curds  may  be  so  numerous  as  to  give  the  stool  the  appearance 
of  curdled  milk.  Occasionally  the  stool  may  be  creamy  in  color  and 
consistency,  this  representing  an  excess  of  neutral  fat.  Micro- 
scopically in  this  third  type,  the  stools  show  an  excess  of  fat  in  the 
form  of  soap,  with  or  without  the  presence  of  free  fatty  acid.  Oc- 
casionally neutral  fat  is  present.  Loss  of  weight  is  apt  to  be  marked 
in  this  t\^e. 

In  the  fourth  type  the  stools  are  loose,  green,  and  strongly  acid. 
They  are  apt  to  cause  marked  irritation  of  the  buttocks.  The  fat 
is  in  combination  with  the  alkahne  salts,  and  there  is  usually  also 
free  fatty  acid.  The  stools  in  this  type  closely  resemble  those  in 
indigestion  from  an  excess  of  carbohydrate,  or  in  indigestion  with 
fermentation.  In  fat  indigestion,  however,  stools  of  this  kind  usu- 
ally represent  a  somewhat  acute  exacerbation,  supervening  upon  one 
of  the  preceding  types.  Microscopically  the  stools  show  an  excess 
of  fat  in  the  form  of  soap,  free  fatty  acid,  and  occasionally,  some 
neutral  fat.     Loss  of  weight  is  usually  extremely  rapid  in  this  type. 

Reaction  to  Feeding. — In  indigestion  from  an  excess  of  fat,  when 
the  quantity  of  fat  in  the  food  is  reduced,  an  improvement  occurs 
in  the  clinical  symptoms.  The  amount  of  reduction  necessary  to 
bring  about  this  improvement  varies  with  the  degree  of  fat  intol- 
erance present  in  the  particular  case.  Sometimes  it  is  necessary  to 
withdraw  cow's  milk  fat  wholly  from  the  food,  in  order  to  relieve 
the  signs  of  indigestion.  The  only  exception  to  the  improvement  in 
the  clinical  symptoms  usually  following  reduction  of  fat  in  the  food, 
is  seen  in  the  type  characterized  by  vomiting.  In  this  type,  the 
vomiting  sometimes  continues,  even  after  all  fat  is  excluded.  This 
occurs  because  the  stomach  has  become  so  irritable,  that  the  mechan- 
ical stimulus  from  the  coagulation  of  the  casein,  or  even  from  the 
mere  presence  of  food  in  the  stomach,  is  sufficient  to  cause  vomiting. 


412  Diseases  of  the  Gastro-Enteric  Tract 

This  fact  should  be  remembered,  as  otherwise  the  continuance  of 
the  vomiting  greatly  obscures  the  diagnosis. 

In  comparatively  mild  cases,  in  which  complete  exclusion  of  fat 
is  not  necessary  for  the  relief  of  symptoms,  the  babies  are  able  to 
gain  weight  when  the  fat  in  the  food  is  reduced.  In  other  more 
severe  cases,  the  babies  begin  to  gain  in  weight  only  when  the  fat 
in  the  food  is  completely  excluded.  Often  the  gain  in  weight  under 
both  these  conditions  may  be  maintained  for  a  considerable  time. 
Usually,  however,  as  these  babies  improve,  their  caloric  requirements 
eventually  rise,  and  they  become  unable  to  gain  in  weight  unless  the 
caloric  value  of  the  food  is  increased.  In  comparatively  mild  cases, 
after  the  digestive  system  is  rested,  fat  can  now  be  increased  in 
the  food,  or  added  to  the  food,  in  an  amount  sufficient  to  maintain 
a  gain  in  body  weight  without  causing  indigestion. 

In  more  difficult  cases  of  fat  indigestion,  the  reduction  of  fat,  or 
exclusion  of  fat,  necessary  for  the  relief  of  symptoms,  does  not  per- 
mit a  gain  in  weight.  In  such  cases,  an  attempt  is  made  to  raise 
the  caloric  value  of  the  food  by  increasing  the  quantity  of  carbo- 
hydrate and  protein.  There  are,  however,  limits  varying  with  the 
individual,  beyond  which  the  carbohydrate  and  protein  cannot  be 
increased  without  danger  of  producing  serious  symptoms  of  indi- 
gestion. The  carbohydrate  is  best  fitted  to  assume  the  role  of  the 
fat  as  a  source  of  energy,  but  an  excess  easily  produces  indigestion, 
and  carbohydrate  indigestion  tends  greatly  to  increase  the  intol- 
erance toward  fat.  While  increase  in  the  protein  is  less  dangerous, 
this  food  element  is  very  uneconomic  as  a  source  of  energy.  There- 
fore, in  serious  cases  of  indigestion  from  an  excess  of  fat,  a  certain 
amount  of  fat  is  necessary  for  proper  metabolism,  yet  cannot  be 
utihzed,  and  we  are  confronted  by  the  difficult  situation  of  inability 
to  give  fat  with  inability  to  attain  a  gain  in  weight  without  it. 

When,  in  such  cases,  the  amount  of  fat  in  the  food  is  increased, 
the  reaction  is  often  deceptive.  The  addition  of  fat  after  complete 
exclusion,  or  increase  in  fat  if  exclusion  was  not  complete,  is  often 
followed  by  an  immediate  response  in  so  far  as  gain  in  weight  is 
concerned.  The  babies  begin  to  gain  most  satisfactorily,  and  clinical 
:symptoms  of  indigestion  often  do  not  reappear  at  once.  The  stools 
may  take  on  the  macroscopic  appearance  of  ''soap  stools,"  and  may 
even  show  microscopically  an  excess  of  fat  in  the  form  of  soap.  Such 
stools,  however,  are  not  incompatible  with  continued  gain  in  weight, 
and  the  macroscopic  appearances  may  gradually  improve,  while  the 
microscopic  excess  of  soap  may  gradually  diminish.  On  the  other 
hand,  in  these  cases,  after  a  variable  period  of  gain  in  weight,  there 
may  occur  a  sudden  appearance  of  symptoms  of  indigestion  such  as 
vomiting,  stools  containing  fatty  curds,  fatty  diarrhea,  or  marked 
increase  of  soap  in  the  stools,  and  in  such  an  acute  exacerbation,  all 


Indigestion  from  an  Excess  of  Fat  413 

the  gain  in  weight  which  has  been  accumulated  may  vanish  within 
twenty-four  or  forty-eight  hours.  Such  a  sudden  reappearance  of 
the  signs  of  fat  intolerance  is  often,  for  abbreviation,  called  a  fat 
"blow-up."  These  "blow-ups"  may  be  serious,  accompanied  by 
toxic  symptoms,  such  as  high  fever,  or  collapse  with  subnormal 
temperature,  rapid,  deep  respiration,  restlessness  or  stupor,  and 
cherry-red  lips.  The  cause  of  the  toxic  symptoms  is  a  marked  dis- 
turbance of  metabolism,  probably  an  acidosis,  as  there  is  increased 
ammonia  excretion  in  the  urine.     A  fat  "blow-up"  may  be  fatal. 

The  management  of  a  case  of  severe  fat  indigestion  is  often  very 
difficult,  because  the  clinical  warning  of  the  approach  of  a  "blow-up'* 
is  often  very  slight.  The  finding  of  excessive  fat  in  the  form  of  soap 
in  the  stools  of  a  baby  who  is  gaining  satisfactorily  in  weight,  is  not 
necessarily  the  sign  of  an  approaching  "blow-up,"  and  if  the  fat  is 
reduced,  the  gain  in  weight  will  probably  cease.  If,  however,  as  a 
result  of  several  micro-chemical  examinations  of  the  stools,  the 
quantity  of  fat  is  found  to  be  increasing,  it  is  probable  that  trouble 
is  approaching.  Other  symptoms  indicating  an  approaching  "blow- 
up" are  the  reappearance  of,  or  increase  in,  the  vomiting;  the  ap- 
pearance of  stools  containing  soft,  fatty  curds,  or  of  loose,  green,, 
acid  stools;  the  appearance,  on  microscopic  examination,  of  neutral 
fat  in  the  stools;  a  sudden  loss  of  weight,  unexplained  by  clinical 
symptoms. 

Clinical  Type  in  Breast-fed  Infants. — ^When  the  quantity  of 
fat  in  breast  milk  is  excessive,  the  principal  symptoms  are  vomiting, 
abnormal  stools,  and  failure  to  gain,  or  loss,  in  weight.  The  vomit- 
ing occurs  in  the  intervals  between  feedings,  and  the  vomitus  is  often 
sour,  usually  without  curds,  but  sometimes  containing  a  substance 
resembling  melted  butter.  The  stools  contain  small  soft  curds,  are 
usually  acid,  and  may  irritate  the  buttocks.  They  are  either  green 
in  color,  or  have  an  oily,  glistening  appearance.  Typical  "soap 
stools"  are  very  unusual.  The  loss  of  weight  is  usually  moderate. 
Loss  of  appetite,  flatulence,  and  colic,  may  be  present.  The  symp-  . 
toms  are  usually  not  severe. 

Clinical  Type  in  Older  iNFANTS.^There  is  a  peculiar  clinical 
type,  particularly  seen  in  the  second  year  of  life,  in  infants  who  are 
no  longer  on  an  exclusively  milk  diet.  There  is  usually  nothing  in 
the  history  to  suggest  overfeeding  with  fat,  or  indeed,  with  any 
particular  food  element.  There  is,  however,  usually  a  history  of 
general  overfeeding,  these  cases  occurring  in  infants  whose  diet  has 
been  increased  too  rapidly,  and  has  become  too  rich  and  varied. 
This  should  properly  produce  symptoms  of  indigestion  from  an 
excess  of  food  as  a  whole,  but  these  symptoms  have  been  overlooked. 
The  occasional  acute  attacks  of  indigestion  which  may  have  occurred 


414 


Diseases  of  the  Gastro-Enteric  Tract 


have  been  attributed  to  accidental  or  temporary  causes,  rather  than 
to  persistent  overfeeding,  and  the  only  marked  chronic  symptom  is 
undigested  stools.  The  stage  of  indigestion  from  simple  overfeeding 
is  consequently  passed  without  attracting  attention,  and  the  repeated 
injuries  from  overfeeding  cause  the  digestive  system  to  show  intol- 
erance toward  fat. 

The  symptoms  are  continued  slight  fever,  restlessness,  irritability, 
and  failure  to  gain  in  weight.  Symptoms  pointing  directly  toward 
the  digestive  system  are  not  marked,  and  although  the  stools  are 
abnormal,  their  character  does  not  attract  the  attention  of  the  child's 
mother.  The  stools  macroscopically  are  apt  to  be  large,  hard,  and 
dry;  microscopically,  whenever  there  is  fat  in  the  diet,  the  stools 
show  excessive  fat  in  the  form  of  soap.  If  fat  is  cut  out  of  the  diet, 
the  stools  improve,  and  the  fever  and  irritability  disappear,  but  the 
child  is  still  unable  to  gain  in  weight,  or  actually  loses.  When  fat 
is  added  to  the  diet,  the  symptoms  reappear. 

Fig.  97 


Infantile  atrophy.     Female,  i>2  years  old 


Epeect  of  Fat  Indigestion  on  Nutrition  and  Metabolism. — 
The  principal  effect  of  defective  power  of  digesting  and  absorbing 
fat,  is  shown  by  a  general  failure  of  nutrition,  which  is  principally 
manifested  in  loss  of  body  weight.  The  continuous  loss  of  calcium 
and  magnesium  in  the  stools  which  occurs  in  many  cases,  may  pro- 
duce a  disturbance  in  the  salt  metabolism.  There  are  two  particular 
manifestations  of  such  disturbance  seen  in  two  distinct  types  of 
malnutrition  to  be  described  in  the  next  division,  namely,  rachitis 
and  spasmophilia;  fat  indigestion  is  a  frequent  contributing  cause  of 
both  of  these.  The  effect  of  acute  exacerbations  in  producing  an 
acidosis,  has  already  been  described. 

Sometimes  the  disturbance  of  metabolism  may  be  very  marked, 
and  the  continued  loss  of  weight  may  lead  to  the  severe  condition 


Indigestion  from  an  Excess  of  Fat  415 

of  malnutrition  known  as  "marasmus,"  or  "infantile  atrophy." 
While  other  forms  of  indigestion  may  lead  to  this  condition,  the 
most  common  is  indigestion  from  excessive  fat.  The  prominent 
feature  of  this  condition  is  the  progressive  and  extreme  loss  of  weight, 
especially  of  the  subcutaneous  adipose  tissue.  The  skin  is  dry 
and  wrinkled,  and  hangs  in  folds  on  the  bones,  giving  the  appear- 
ance of  a  living  skeleton  or  advanced  old  age.  The  bones  of  the 
head  frequently  overlap  and  the  anterior  fontanelle  is  usually  de- 
pressed. The  extremities  are  cool.  The  abdomen  soon  becomes 
sunken.  The  tongue  is  dry  and  usually  reddened.  The  pulse  is 
feeble  and  usually  rapid.  The  temperature  is  normal,  or  more  com- 
monly subnormal,  but  in  some  cases  is  raised.  The  respirations  are 
generally  normal.  Although  secondary  anemia  is  quite  a  prominent 
condition,  extreme  pallor  is  not  usual.  In  some  cases,  although  the 
skin  is  pale,  the  blood  count  shows  an  increase  in  hemoglobin  and 
red  blood  corpuscles,  due  to  concentration  of  the  blood.  There  is 
no  characteristic  change  in  the  leucocytes.  The  appetite  is  usually 
lessened,  but  may  be  at  times  voracious. 

Fig.  98 


Infantile  atrophy.     Female,  9  months  old 

DIAGNOSIS. — The  diagnosis  of  indigestion  from  a  relative  excess 
of  fat  depends  mainly  on  two  clinical  features,  first,  the  reaction  of 
the  patient  toward  the  quantity  of  fat  given  in  the  food,  and  second, 
the  character  of  the  stools.  These  features  have  been  described  under 
symptoms.  There  are,  however,  a  number  of  types  in  which  diag- 
nosis is  particularly  difficult. 

The  type  in  which  vomiting  is  the  principal  symptom  must  be  distin- 
guished from  a  number  of  conditions  in  which  vomiting  is  a  prominent 
symptom.  Pyloric  stenosis  and  spasm  are  excluded  by  the  absence 
of  their  peculiarly  characteristic  symptoms,  such  as  visible  peristalsis, 
delayed  emptying  time  of  the  stomach,  and  so  forth,  and  by  the 
presence  in  the  vomitus  of  signs  of  indigestion.  Indigestion  from 
overfeeding  may  cause  vomiting,  but  the  symptom  is  easily  relieved 
by  reduction  in  the  strength  of  the  food,  without  the  occurrence  of 


416  Diseases  of  the  Gastro-Enteric  Tract 

loss  of  weight.  Indigestion  from  carbohydrate  may  cause  vomiting^ 
but  there  are  usually  also  loose,  green,  acid,  irritating  stools,  with 
much  gas,  and  the  vomiting  is  relieved  by  changing  the  quantity  or 
variety  of  carbohydrate  in  the  food.  Furthermore  the  vomitus  has 
not  the  butyric  acid  odor  characteristic  of  indigestion  from  fat.  In 
indigestion  from  protein,  the  vomiting  usually  occurs  soon  after 
feeding,  the  vomitus  usually  contains  large  curds,  and  has  no  butyric 
acid  odor.  In  fat  indigestion,  the  confirmation  of  the  diagnosis  often 
depends  on  the  improvement  in  symptoms  following  reduction  of 
the  fat  in  the  food.  In  some  cases,  in  which  the  stomach  has  become 
very  irritable,  no  improvement  follows  when  fat  is  excluded  from  the 
diet.  In  such  cases  it  is  difficult  to  make  a  diagnosis.  One  can 
suspect  fat  indigestion  from  the  previous  history,  and  this  is  the 
commonest  cause  of  such  resistant  cases. 

The  type  characterized  by  soap  stools  is  sometimes  difficult  to  recog- 
nize. The  indigestion  is  not  conspicuous  macroscopically,  and  a 
practical  problem  which  frequently  arises  is  this, — is  failure  to  gain 
in  weight  a  sign  that  the  infant  needs  a  food  of  higher  caloric  value,, 
or  a  sign  that  it  is  getting  too  much  fat  for  its  powers  of  digestion. 
The  result  of  the  micro-chemical  examination  of  the  stools  is  inval- 
uable in  setthng  this  question,  and  is  the  principal  guide  in  directing 
the  treatment. 

The  type  characterized  by  soft,  fatty  curds  is  the  one  most  t}^ical 
of  fat  indigestion,  and  the  easiest  to  recognize.  The  diagnosis  is 
confirmed  by  the  finding  of  an  excess  of  soap,  often  with  free  fatty 
acid  in  the  stools  on  microscopic  examination,  and  by  the  reaction 
of  the  patient  toward  attempts  to  feed  fat. 

The  type  characterized  by  loose,  green,  irritating  movements  is  difii- 
cult  to  distinguish  from  indigestion  from  carbohydrate,  and  indiges- 
tion with  fermentation.  The  results  of  the  micro-chemical  exami- 
nation of  the  stools  are  not  conclusive,  as  an  excessive  amount  of 
fat  may  be  eliminated  in  the  diarrhea  caused  by  both  carbohy- 
drate indigestion  and  fermentation.  Indigestion  from  carbohydrate 
is,  however,  quickly  relieved  by  a  change  in  the  quantity  or  variety 
of  the  carbohydrate,  while  in  fat  indigestion  the  symptoms  are  only 
reHeved  by  a  reduction  of  the  fat.  In  indigestion  with  fermentation 
the  diarrhea  is  usually  much  more  severe  than  in  fat  indigestion, 
and  it  is  not  reHeved  by  a  reduction  of  the  fat. 

In  older  infants  the  diagnosis  rests  entirely  upon  the  results  of 
the  micro-chemical  examinations  of  the  stools  for  fat,  and  upon  the 
effect  of  the  attempts-  to  give  fat. 

Infantile  atrophy  due  to  fat  indigestion  must  be  distinguished 
from  similar  conditions  of  malnutrition  produced  by  such  diseases 
as  tuberculosis,  syphilis,  and  other  forms  of  chronic  indigestion. 
The  first  two  are  excluded  by  absence  of  their  characteristic  diag- 


Indigestion  from  an  Excess  of  Fat  417 

nostic  features.     It  must  be  remembered,  however,  that  fat  intol- 
erance is  frequently  seen  in  chronic  tuberculosis. 

PROGNOSIS. — The  prognosis  of  indigestion  from  an  excess  of 
fat  is  very  variable.  There  are  the  greatest  extremes  of  variation  in 
the  degrees  of  fat  intolerance  encountered,  in  the  length  of  time  the 
symptoms  have  persisted,  and  in  the  degree  of  malnutrition  which 
has  been  reached.  The  prognosis  depends  upon  all  these  factors. 
As  the  degree  of  fat  intolerance  cannot  be  estimated  until  treatment 
has  been  attempted,  it  is  impossible  for  the  physician  to  give  a  prog- 
nosis when  he  first  sees  a  case. 

In  general,  in  artificially  fed  infants,  indigestion  from  fat  is  the 
most  resistant  and  difficult  to  treat  of  all  the  chronic  forms  of  indi- 
gestion, and  the  acute  exacerbations  which  occur  from  time  to  time 
are  decidedly  dangerous,  and  may  be  fatal.  When  the  intolerance 
toward  fat  is  not  marked,  and  the  baby  is  able  to  gain  with  a  reduced 
quantity  of  fat  in  the  food,  the  prognosis  is  good.  When,  however, 
the  baby  shows  a  higher  caloric  requirement  than  can  be  given  him 
without  the  production  of  symptoms  of  fat  indigestion,  the  outlook 
is  less  encouraging.  With  proper  treatment,  most  of  these  cases 
eventually  recover,  if  malnutrition  has  not  become  extreme,  and  if 
no  intercurrent  acute  disease  supervenes,  but  the  physician  must 
recognize  that  he  has  a  long  and  arduous  struggle  before  him. 

In  the  type  described  above  as  occurring  during  the  second  year 
in  infants  taking  a  more  varied  diet,  the  prognosis  is  good  for  eventual 
recovery,  but  much  patience  is  needed,  and  many  months  are  often 
required.  Neither  the  physician  nor  the  parents  must  expect  either 
an  immediate  or  a  rapid  gain  in  weight,  and  often  the  best  treatment 
is  that  which  results  in  no  gain  in  weight  for  weeks  or  even  months. 

In  breast-fed  babies  the  prognosis  is  usually  good. 

TREATMENT.  In  Artificially  Fed  Infants. — The  principle 
of  treatment  is  to  reduce  the  quantity  of  fat  in  the  food  to  a  point 
at  which  it  will  be  within  the  infant's  powers  of  digestion  and  ab- 
sorption. This  necessarily  reduces  the  caloric  value  of  the  food, 
which  must  be  made  up  by  some  increase  in  the  carbohydrate  or 
protein  or  both. 

The  amount  by  which  the  fat  must  be  reduced  depends  on  the 
severity  of  the  case.  Some  estimate  of  the  degree  of  intolerance  for 
fat  can  often  be  made  from  a  careful  study  of  the  previous  feeding 
of  the  infant.  Even  in  apparently  mild  cases  it  is  not  wise  to  begin 
with  more  than  2  per  cent  of  fat.  In  severe  cases,  i  per  cent  is 
better,  and  in  any  case  suffering  from  acute  symptoms,  such  as 
diarrhea  or  intoxication,  it  is  best  to  cut  out  the  fat  entirely.  The 
carbohydrate  should  not  exceed  7  per  cent;  if  there  is  any  suspicion 

27 


418  Diseases  oe  the  Gastro-Enteric  Teact 

of  previous  carbohydrate  indigestion,  it  should  not  exceed  5  or  6 
per  cent. 

As  to  the  kind  of  extra  carbohydrate  to  be  added,  whether  lactose 
or  maltose,  I  beheve  dextri-maltose  to  be  better  in  general  in  cases 
of  fat  indigestion.  This  is  because  maltose  is  less  fermentable  than 
lactose,  is  more  easily  absorbed,  and  is  all  absorbed  in  the  form  of 
dextrose  so  that  it  can  be  more  immediately  utihzed  for  purposes 
of  energy  production  without  having  to  go  through  the  process  of 
glycogen-storing  in  the  liver.  Babies  with  fat  intolerance  cannot  usu- 
ally digest  more  fat  when  maltose  is  used  than  when  lactose  is  used, 
except  in  some  cases  where  the  fat  intolerance  has  been  increased 
by  coexistent  carbohydrate  fermentation.  They  can,  however,  often 
gain  weight  on  a  lower  percentage  of  fat  when  maltose  is  used  instead 
of  lactose,  the  reason  probably  being  that  with  maltose  more  carbo- 
hydrate is  absorbed  and  utilized.  Sometimes,  however,  maltose  will 
cause  indigestion  and  the  babies  will  do  better  on  lactose,  but  this 
is  rare.  The  maltose  may  be  given  in  the  form  of  dextri-maltose, 
or  of  a  malt  extract.  The  former  is  preferable  for  routine  use  as  it 
is  less  laxative. 

The  protein  should  be  from  1.5  to  2  per  cent  at  the  start.  The 
split  protein  should  not  be  used,  as,  with  our  present  knowledge  of 
the  subject  the  giving  of  a  large  quantity  of  the  whey  salts  should 
be  avoided. 

If  the  baby  is  able  to  gain  in  weight  on  the  first  food  given,  the 
formula  should  not  be  changed,  for  a  time  at  least.  It  must  be 
remembered,  however,  that  while  the  resting  of  a  function  leads  to 
recovery  and  increase  of  functional  power  at  first,  too  prolonged 
rest  tends  to  weaken  it.  The  power  of  digesting  fat  can  be  weak- 
ened by  too  prolonged  use  of  a  food  low  in  fat  content.  Conse- 
quently, even  if  babies  are  gaining  weight,  cautious  efforts  should 
be  made  from  time  to  time  to  increase  the  quantity  of  fat  in  the 
food.  Such  increases  should  not  exceed  0.25  per  cent  at  a  time, 
and  should  always  be  controlled  by  careful  examinations  of  the  stools. 

When  a  baby  is  unable  to  gain  in  weight  on  the  first  food  given, 
or  when  after  a  tem.porary  gain,  the  weight  becomes  stationary,  or 
begins  to  decHne,  the  question  arises  as  to  whether  the  inability  to 
gain  is  due  to  too  low  caloric  intake,  or  to  the  fact  that  the  amount 
of  fat  in  the  food  is  still  excessive.  Obviously,  if  all  fat  has  been 
cut  out,  failure  to  gain  must  be  due  to  a  food  too  low  in  calories. 
If  some  fat  is  being  given,  the  question  is  settled  by  the  symptoms, 
and  particularly  by  the  results  of  the  examinations  of  the  stools. 
If  s>Tnptoms  still  persist,  or  if  the  stools  still  show  fatty  curds,  or 
micro-chemically  a  large  excess  of  fat,  the  fat  must  be  still  further 
reduced,  or  cut  out  entirely.  It  is  essential  that  at  the  beginning 
of  treatment  the  signs  of  fat  indigestion  be  eliminated. 


Indigestion  from  an  Excess  of  Fat  419 

Frequent  careful  examinations  of  the  stools  are  essential  to  the 
proper  management  of  a  case  of  indigestion  from  excess  of  fat.  Such 
an  examination  should  be  made  as  a  matter  of  routine,  on  the  second 
day  after  every  change  in  the  composition  of  the  food,  and  at  other 
times,  every  two  or  three  days,  until  the  feeding  has  become  estab- 
lished. After  this  a  micro-chemical  examination  should  be  made 
once  a  week. 

When  the  physician  is  convinced  that  symptoms  of  fat  indigestion 
have  been  eliminated  by  reduction  of  the  fat,  and  that  failure  of  the 
patient  to  gain  in  weight  is  due  to  an  insufficient  caloric  intake,  he 
should  first  increase  the  carbohydrate  and  protein.  The  carbohy- 
drate may  be  raised  to  7  per  cent,  and  the  protein  gradually  to  2.5 
or  3  per  cent,  symptoms  of  indigestion  being  carefully  watched  for. 
Such  symptoms  are  a  sign  that  the  limit  of  tolerance  for  that  par- 
ticular food  element  has  been  passed,  and  that  its  quantity  must 
be  reduced. 

If  the  raising  of  the  carbohydrate  and  protein  within  the  limits 
of  tolerance  do  not  permit  a  steady  gain  in  weight,  then  the  fat  must 
be  increased.  Increase  in  the  quantity  of  fat  must  always  be  grad- 
ual, not  more  than  0.25  or  0.5  per  cent  at  a  time,  and  should  be  care- 
fully controlled  by  the  results  of  the  micro-chemical  examinations 
of  the  stools  for  fat.  When,  after  the  increase  in  the  fat,  the  baby 
finally  begins  to  gain  in  weight,  no  further  increase  should  be  made. 
Even  with  the  baby  gaining  in  weight,  the  stools  should  be  carefully 
watched.  The  mere  presence  of  an  excess  of  fat  in  the  form  of  soap 
in  the  stools  is  not  a  contraindication  to  leaving  the  baby  on  the  formula 
on  which  he  is  gaining.  In  such  cases,  a  fat  "blow-up"  may  be  ap- 
proaching, or  the  baby's  digestive  powers  may  be  gradually  adjust- 
ing themselves  to  the  quantity  of  fat  which  is  being  given.  If, 
however,  the  amount  of  fat  in  the  stools  is  increasing,  and  especially 
if  the  macroscopic  appearance  of  the  stools  is  becoming  worse,  or 
if  any  other  symptoms  of  fat  indigestion  reappear,  then  the  fat  must 
again  be  reduced  for  a  time,  even  if  gain  in  weight  temporarily  ceases. 

A  case  in  which  a  gain  in  weight  cannot  be  attained  and  main- 
tained under  the  above  outline  of  dietetic  management,  comes  into 
the  category  of  a  resistant  case. 

Resistant  Cases. — The  most  satisfactory  food  in  indigestion  from 
a  relative  excess  of  fat  is  human  milk.  Owing  to  the  difficulty  in 
this  country  of  obtaining  wet-nurses,  human  milk  cannot  be  used  to 
any  great  extent,  and  comparatively  mild  cases  will  often  do  fairly 
well  with  artificial  feeding.  In  any  case,  however,  in  which  attempts 
at  artificial  feeding  have  shown  that  the  infant  belongs  to  the  class 
•of  resistant  cases,  a  wet-nurse  should  be  obtained  whenever  possible. 
Moreover,  with  any  case  which  at  the  time  of  beginning  treatment 


420  Diseases  of  the  Gastro-Enteric  Tract 

is  already  in  a  condition  of  extreme  malnutrition,  it  is  better  not  to 
waste  time  with  attempts  at  artificial  feeding,  but  to  use  a  wet-nurse 
at  once,  provided  one  can  be  obtained.  Even  if  a  baby  cannot  be 
put  entirely  on  human  milk,  any  amount  of  human  milk  which  can 
be  obtained  is  a  very  valuable  adjunct  to  the  treatment.  The  man- 
agement of  resistant  cases  under  artificial  feeding  must  be  described 
here,  because  human  milk  cannot  always  be  obtained. 

Albumin  milk  has  been  widely  recommended  in  the  treatment  of 
cases  of  severe  malnutrition.  In  my  experience,  babies  with  fat 
indigestion  cannot  take  more  fat  when  albumin  milk  is  substituted 
for  ordinary  mixtures.  Some  babies,  however,  will  do  better  and 
will  gain  weight  on  a  lower  quantity  of  fat  when  albumin  milk  is 
used.  This  is  probably  due  to  the  form  in  which  the  protein  is  given 
in  albumin  milk.  The  combination  of  precipitated  casein  with  lactic 
acid  milk,  which  constitutes  albumin  milk,  is  in  my  experience  not 
essential.  In  a  resistant  case  I  order  definite  quantities  of  fat,  car- 
bohydrate, and  protein,  as  before,  merely  providing  that  the  protein 
shall  be  added  in  a  precipitated  form  in  the  percentage  wliich  I  wish 
to  give.  The  quantities  of  the  various  food  elements  may  then 
again  be  varied  in  various  ways  in  the  effort  to  attain  a  proper  gain 
in  weight  without  symptoms  of  indigestion. 

Some  individual  babies  appear  to  do  better  on  lactic  acid  milk 
than  on  precipitated  casein.  Therefore,  if  precipitated  casein  fails, 
lactic  acid  milk  may  be  tried. 

There  is  no  proven  method  of  modifying  cow's  milk  by  which  the 
tolerance  for  fat  can  be  actually  increased.  The  new  method  of 
using  homogenized  olive  oil  described  in  the  division  on  feeding,  has 
given  some  evidence  of  increasing  the  power  to  digest  and  absorb 
fat  in  resistant  cases.  This  method  of  modifying  milk  has  not  yet 
become  generally  available,  but  offers  some  future  promise  as  a 
weapon  in  resistant  cases  of  fat  indigestion. 

One  type  coming  under  the  heading  of  resistant  cases  is  that  char- 
acterized by  vomiting,  in  which  the  stomach  has  become  so  irritable 
and  intolerant  that  the  vomiting  does  not  cease  even  after  fat  is 
wholly  cut  out  of  the  food.  In  such  cases  it  is  probable  that  the 
immediate  exciting  irritant  is  casein,  and  the  various  methods  of 
modifying  cow's  milk,  which  aim  to  make  the  casein  more  digestible, 
should  be  tried  in  turn.  I  have  obtained  the  best  results  with 
sodium  citrate,  given  in  the  amount  of  0.4  per  cent  of  the  milk  and 
cream;  but  other  alkahes  may  be  tried.  The  addition  of  0.75  per 
cent  starch  will  sometimes  help.  Daily  gastric  lavage  is  an  im- 
portant adjunct  to  the  treatment  in  these  cases. 

In  some  resistant  cases,  if  the  physician  can  reconcile  himself  to 
a  period  of  loss  of  weight,  or  failure  to  gain,  while  keeping  the  quan- 
tity of  fat  in  the  food  very  low,  and  thus  avoid  symptoms  of  fat 


Indigestion  from  an  Excess  of  Fat  421 

indigestion  or  a  fat  "blow-up,"  he  will  often  find  that  in  time  the 
tolerance  for  fat  will  have  improved  and  that  the  patient  will  finally 
begin  to  do  better. 

Treatment  of  a  Fat  "Blow-up." — A  fat  "blow-up"  is  an  attack 
of  acute  indigestion  from  excess  of  fat.  Its  symptoms  have  been 
described.  In  such  a  case,  if  human  milk  can  be  obtained,  it  should 
be  utilized.  If  it  cannot  be  obtained,  all  fat  should  be  cut  out  of 
the  food.  Heaters  and  stimulation  are  sometimes  required.  I  have 
obtained  a  remarkably  good  response  in  certain  desperate  cases  of 
acute  fat  indigestion,  by  the  intravenous  injections  of  three  or  four 
ounces  of  a  5  per  cent  dextrose  solution.  I  am  convinced  that  the 
sugar  will  not  cause  an  intoxication,  nor  add  to  the  toxic  symptoms, 
when  given  in  this  way,  and  that  much,  if  not  all  of  it,  is  utilized 
for  actual  energy  production. 

Treatment  of  the  Type  Seen  in  Older  Children. — The  general 
principles  of  treatment  of  the  type  of  fat  indigestion  which  occurs 
in  the  second  year  of  life,  and  sometimes  in  the  third  or  fourth,  are 
much  like  those  used  in  the  treatment  of  the  younger  artificially  fed 
infants.  The  difference  is  that  the  physician  has  at  his  disposal  an 
increased  number  of  forms  in  which  he  can  give  carbohydrate  and 
protein.  The  treatment  consists  in  continual  minute  regulation  of 
the  diet,  the  idea  being  to  give  as  much  carbohydrate  and  protein 
as  can  be  given  without  producing  indigestion  from  an  excess  of 
those  food  elements.  The  fat  must  be  kept  reduced  to  a  point  where 
an  excess  does  not  appear  in  the  stools.  Under  such  treatment  the 
children  often  will  not  gain  for  a  considerable  time,  but  if  patience 
be  exercised,  eventually  the  tolerance  for  fat  will  rise,  and  as  soon 
as  they  can  take  a  sufficiency  of  fat,  they  will  begin  to  gain.  The 
giving  of  fat  must  be  closely  controlled  by  micro-chemical  examina- 
tions of  the  stools.  In  beginning  the  treatment  of  such  cases,  skimmed 
milk  with  the  addition  of  some  extra  dextri-maltose  should  form 
the  basis  of  the  diet.  Other  carbohydrate  and  protein  articles  of 
diet  should  be  added,  according  to  the  age  of  the  infant.  Eventually 
the  cream  should  be  gradually  added  to  the  milk. 

Treatment  in  Breast-fed  Infants. — The  disturbance  of  diges- 
tion caused  by  an  excessive  quantity  of  fat  in  breast  milk,  is  usually 
easily  corrected.  If  the  mother  has  been  eating  an  excessive  amount 
of  fat,  this  should  be  reduced.  Ordinarily,  however,  the  mother  has 
been  eating  too  much  in  general,  rather  than  too  much  fat.  The 
amount  of  her  food  as  a  whole  should  be  reduced,  and  the  amount  of 
exercise  which  she  takes  out  doors  should  be  increased.  In  the  mean- 
time, the  duration  of  nursing  should  be  shortened,  so  that  the  breast 
may  not  be  completely  emptied;  it  is  known  that  the  last  milk  con- 
tains more  fat.     The  breast  milk  may  be  diluted  by  the  giving  of 


422  Diseases  of  the  Gastro-Enteric  Tract 

boiled  water  immediately  before  each  nursing,  and  this  should  be 
continued  until  the  hygienic  regulation  of  the  mother  has  produced 
a  reduction  of  the  fat  in  the  milk.  Sometimes,  if  the  duration  of 
the  nursing  is  shortened,  it  is  necessary  also  to  shorten  the  intervals 
between  feedings,  in  order  that  the  baby  may  get  enough  food. 

PROBLEMS  AND  RESEARCH.— The  most  important  problem 
connected  with  indigestion  from  an  excess  of  fat  in  the  food  has  to 
do  with  etiology.  The  normal  baby,  when  studied  experimentally, 
appears  to  show  no  particular  difficulty  in  digesting  and  absorbing 
cow's  milk  fat.  On  the  other  hand,  babies  with  a  weakened  diges- 
tive power  appear  to  show  a  special  intolerance  for  cow's  milk  fat, 
while  the  fat  of  human  milk  is  digested  with  much  greater  ease. 
The  question  to  be  solved  is  whether  the  inability  to  digest  cow's 
milk  fat  is  a  particular  manifestation  of  general  congenital  weak- 
ness of  digestive  power,  or  whether  it  develops  as  the  result  of  the 
abuse  of  the  digestive  system  through  faulty  methods  of  feeding. 
If  the  latter,  what  particular  errors  in  feeding  are  most  hkely  to  pro- 
duce a  diminished  power  of  digesting  fat? 

We  only  know  that  an  amount  of  fat  too  great  for  the  infant's 
powers  of  digestion  and  metabolism  causes  functional  disturbance  of 
digestion  and  metabolism.  We  do  not  know  why  comparatively 
small  amounts  of  cow's  milk  fat  often  constitute  a  relative  excess. 
We  do  not  know  whether  the  reason  lies  in  the  chemical  composition 
of  cow's  milk  fat,  which  differs  from  the  fat  of  human  milk,  whether 
it  lies  in  the  different  salt  content  of  cow's  milk,  or  whether  the 
primary  injury  comes  from  some  other  form  of  indigestion,  which 
so  damages  the  digestive  function,  that  cow's  milk  fat  cannot  be 
digested.     Possibly  all  these  factors  play  a  part. 

We  have  learned  that  inability  to  digest  fat  works  a  far-reaching 
injury  upon  nutrition  and  metaboUsm.  Nevertheless,  the  mechanism 
of  the  absorption  and  metabolism  of  fat  is  still  very  imperfectly 
understood,  and  the  complete  nature  of  the  disturbances  caused  by 
an  excess  is  still  unknown.  We  must  look  to  further  studies  on 
metabolism  with  improved  technique,  and  to  further  advance  in 
physiological  chemistry,  for  the  solution  of  these  problems. 

INDIGESTION   FROM   AN   EXCESS   OF   CARBOHYDRATE 

DIGESTION  AND  METABOLISM  OF  CARBOHYDRATE.— 

A  summary  of  the  known  facts  as  to  the  digestion  and  absorption  of 
carbohydrate  is  necessary  for  an  understanding  of  the  disturbances 
caused  by  a  relative  excess. 

Role  of  the  Carbohydrate. — The  carbohydrates  have  two  im- 
portant functions  in  digestion  and  metabolism.  Their  principal  use 
is  similar  to  that  of  the  fat,  in  that  after  absorption  they  serve  not 


Indigestion  from  an  Excess  of  Carbohydrate         423 

as  tissue  builders,  but  as  sources  of  energy.  The  caloric  value  of 
the  sugars  and  starches  is  the  same,  and  is  less  than  that  of  the  fat. 
A  second  function  of  the  carbohydrate  is  exercised  in  the  intestinal 
canal  itself.     This  function  will  be  described  later. 

Chemistry  of  the  Carbohydrate. — The  carbohydrates  most 
used  in  infant  feeding  are  the  three  soluble  sugars  and  starch.  The 
three  soluble  sugars  are  lactose,  or  milk  sugar,  maltose,  or  malt 
sugar,  and  saccharose,  or  cane  sugar.  Maltose  is  not  used  in  its 
pure  form,  on  account  of  its  cost.  The  various  commercial  prepa- 
rations of  maltose  are  combinations  of  maltose  with  various  dex- 
trins,  but  as  in  digestion  dextrin  is  converted  into  maltose,  the 
chemistry  is  practically  the  same. 

These  three  sugars  are  all  disaccharids,  that  is,  combinations  of 
two  simpler  sugars  called  monosaccharids.  They  may,  by  the  action 
of  ferments,  be  split  into  their  component  monosaccharids.  The 
table  shows  the  composition  of  the  three  disaccharids  most  used 
in  the  food  of  infants  and  young  children. 

Table  43 

Chemistry  of  the  Sugars 

Lactose  Saccharose  Maltose 

Dextrose  +  Galactose  Dextrose  +  Levulose  Dextrose  +  Dextrose 

Starch  is  broken  down  by  the  action  of  ferments  into  various 
forms  of  dextrin,  and  the  dextrin  is  finally  converted  into  maltose. 

Digestion  of  the  Carbohydrates. — Although  an  amylolytic 
ferment  is  present  in  the  saliva,  even  of  the  new-born  infant,  salivary 
digestion  is  unim.portant  in  infancy.  The  carbohydrates  are  but 
little  acted  upon  in  the  stomach,  and  pass  quickly  into  the  intestine, 
where  they  encounter  the  various  digestive  ferments  concerned  in 
their  splitting.  These  are  chiefly  lactase  which  spHts  milk  sugar, 
invertin  which  splits  cane  sugar,  maltase  which  splits  malt  sugar, 
amylase  which  breaks  down  starch.  These  ferments  are  present 
from  birth.  They  split  the  carbohydrates  into  their  component 
monosaccharids . 

Absorption  and  the  Metabolism  of  the  Carbohydrates. — The 
carbohydrates,  in  their  more  complex  disaccharid  forms  cannot  be 
utilized  in  metaboHsm.  If  milk  sugar  be  injected  into  the  circula- 
tion, it  will  all  be  excreted  in  the  urine.  If  cane  sugar  be  injected, 
about  65%  will  be  excreted  in  the  urine,  and  the  rest  into  the 
intestinal  canal.  Consequently,  the  carbohydrates  must  be  absorbed 
in  the  form  of  monosaccharid. 

The  monosaccharids  after  absorption  are  taken  up  by  the  portal 
vein,  then  converted  into  glycogen,  and  are   stored  in   that   form. 


424  Diseases  of  the  Gastro-Exteric  Tract 

Glycogen  is  stored  mainly  in  the  liver,  but  somewhat  in  other  parts 
of  the  body.  \Mien  the  carbohydrate  is  needed  for  energy  produc- 
tion, the  glycogen  is  reconverted  by  the  maltase  in  the  blood  into 
dextrose,  in  which  form  it  is  utilized.  The  final  products  of  carbo- 
hydrate combustion  are  carbon  dioxide  and  water.  The  normal 
amount  of  dextrose  in  the  blood  is  one-tenth  per  cent. 

Not  all  the  carbohydrate  given  in  the  food  can  be  assimilated. 
Various  figures  have  been  given  on  the  Hmits  of  assimilation  of  the 
difl'erent  sugars.  These  figures  are  not  in  any  way  an  accurate 
measure  of  the  percentage  of  sugar  which  can  be  absorbed  and 
utihzed.  They  are  based  on  the  amount  of  sugar  which  can  be 
given  to  babies  without  the  appearance  of  sugar  elimination  in  the 
urine.  In  my  experience,  an  excessive  amount  of  sugar  is  not  often 
shown  by  sugar  elimination  in  the  urine.  There  is  no  way  of  esti- 
mating the  proportion  of  sugar  which  is  not  absorbed,  because  the 
sugar  is  not  ehminated  in  the  stools  in  any  measurable  form.  Sugar 
is  not  found  in  the  stools,  except  in  diarrhea  or  other  exceptional 
conditions.  The  sugar  which  is  not  absorbed  is  broken  down  b}^ 
the  bacteria  of  the  intestine  into  a  great  variety  of  fermentation 
products,  among  them  being  lactic,  butyric,  acetic,  and  succinic  acids. 

Carbohydrate  Fermentation  in  the  Intestine. — It  is  probable 
that  Nature  does  not  intend  that  aU  the  carbohydrate  in  the  food 
shall  be  absorbed,  but  designs  a  certain  proportion  of  it  for  fermen- 
tation in  the  intestine.  All  the  disaccharids  are  fermentable.  It  is 
probable  that  a  certain  amount  of  fermentable  carbohydrate  is  neces- 
sary for  the  maintenance  of  a  normal  condition  of  the  intestinal 
flora.  It  is  the  normal  bacterial  fermentation  of  the  excess  of  carbo- 
hydrate in  the  food  which  keeps  the  reaction  of  the  intestinal  canal 
acid.  Furthermore,  it  has  been  shown  that  an  adequate  amount  of 
carbohydrate  in  the  food  makes  the  digestion  of  the  protein  more 
complete.  This  is  probably  because  the  normal  intestinal  bacteria 
five  preferably  upon  the  carbohydrate,  and  do  not  attack  the  protein. 

The  carbohydrates  dift'er  in  the  readiness  with  which  they  are 
broken  down  and  absorbed.  Maltose  is  the  one  most  quickly  broken 
down,  and  consequently  is  the  least  fermentable.  Lactose  is  the 
one  least  rapidly  broken  down  and  absorbed,  and  is  consequently 
the  sugar  best  fitted  to  provide  a  food  for  the  normal  bacteria  of  the 
intestine,  to  maintain  an  acid  reaction,  and  to  spare  nitrogen.  It 
is  probably  for  this  reason  that  Nature  provides  that  the  sugar  in 
human  milk  is  lactose,  and  that  it  is  as  large  in  amount  as  seven 
per  cent. 

Effect  of  an  Excess  of  Carbohydrate. — As  sugar  is  destined  to 
play  a  dual  role  in  digestion  and  metabolism,  one  being  absorption 
and  assimilation,  the  other  being  fermentation,  it  might  be  expected 


Indigestion  from  an  Excess  of  Carbohydrate  425 

that  an  excess  of  sugar  would  have  two  possible  effects,  one  exercised 
upon  the  general  metabolism,  the  other  exercised  locally  upon  the 
intestinal  function.  Many  writers  have  described  the  eft'ect  of  the 
excessive  absorption  of  sugar.  It  has  been  believed  that  sugar  may 
cause  fever  and  intoxication,  and  this  view  has  been  widely  held. 
In  the  light  of  the  most  recent  work  on  the  subject,  however,  it 
appears  that  the  gi^ang  of  an  excessive  amount  of  sugar  in  the  food 
is  not  followed  by  fever,  intoxication,  or  any  other  specific  eft'ect 
upon  metabolism.  It  is  probable  that  either  the  excess  is  not  ab- 
sorbed, or,  if  there  is  increased  absorption,  all  of  the  sugar  is  nor- 
mally utilized. 

The  effect  of  excessive  ingestion  of  carbohydrate  is  probably  con- 
fined to  the  intestinal  canal.  There  is  an  increase  in  bacterial  fer- 
mentation beyond  the  normal.  The  result  is  a  marked  increase  in 
the  acidity  of  the  intestinal  contents,  which  increase  may  involve 
the  whole  or  only  a  part  of  the  canal.  The  increased  quantity  of 
acid  acts  as  an  irritant  to  the  intestinal  mucosa,  and  this  results 
in  an  increase  of  peristalsis.  The  irritating  food  is  thus  removed 
from  the  bowel.  The  nutrition  of  the  child  is  interfered  with,  because 
not  only  is  carbohydrate  lost  to  absorption,  but  the  increased  peris- 
talsis carries  out  large  amounts  of  fat,  protein,  and  salts  which  would 
otherwise  be  retained  and  absorbed. 

Another  effect  of  the  excessive  fermentation  which  results  from  a 
relative  excess  of  carbohydrate  in  the  food,  is  the  formation  of  an 
excessive  amount  of  gas.  This  may  cause  abdominal  distention,  and, 
extending  backward,  it  may  carry  irritating  acid  products  into  the 
stomach,  and  thus  cause  vomiting. 

An  excess  of  starch  may  act  in  the  same  way.  Starch  is  broken 
down  slowly,  but  the  maltose  which  is  formed  is  quickly  absorbed. 
Starch  may,  however,  undergo  fermentation,  with  the  formation  of 
irritant  acids. 

While  lactose  is  theoretically  the  most  readily  fermentable  of  the 
carbohydrates,  cases  are  seen  in  which  excessive  fermentation  appears 
to  take  place  more  easily  with  cane  sugar,  or  even  with  maltose. 
These  cases  are  probably  explained  by  variations  in  the  prevalence 
of  various  varieties  of  intestinal  bacteria. 

ETIOLOGY. — Indigestion  from  carbohydrate  is  caused  by  the 
gi\dng  in  the  food  of  a  quantity  of  carbohydrate  too  great  for  the 
digestive  power  of  the  child.  The  individual  variation  in  the  power 
of  sphtting  and  absorbing  carbohydrate  met  with  in  different  infants 
and  children  is  due  to  the  causes  described  under  the  General  Etiol- 
ogy of  disturbances  of  digestion,  x^ctual  overfeeding  with  carbo- 
hydrate is,  however,  relatively  more  important  in  this  condition  than 
is  weakness  of  digestive  power. 


426  Diseases  of  the  Gastro-Enteric  Tract 

In  breast-fed  babies  indigestion  from  an  excess  of  sugar  is  ex- 
tremely uncommon.  In  artificially-fed  babies  the  disease  is  compara- 
tively common,  and  it  is  one  of  the  commonest  forms  of  indigestion 
seen  in  older  children. 

In  artificially-fed  babies  overfeeding  with  carbohydrates  is  a  com- 
mon fault.  It  is  particularly  encountered  in  babies  fed  on  one  of 
the  patent  foods.  Most  of  the  patent  foods  which  are  added  to 
cow's  milk  mixtures  are  composed  mainly  of  carbohydrate.  These 
foods  are  advertised  as  being  particularly  beneficial  to  babies,  and 
mothers  are  often  tempted  to  increase  the  quantity  of  infant  food 
added  to  the  milk,  beyond  the  limits  of  the  physician's  order  or  of 
the  directions  accompanying  the  food,  in  the  hope  of  increasing  the 
beneficial  action.  Condensed  milk  is  also  frequently  associated  with 
carbohydrate  indigestion,  on  account  of  its  high  cane-sugar  content. 

There  are  variations  in  the  susceptibility  of  infants  to  overfeeding 
with  carbohydrate  in  general,  and  to  the  several  forms  of  carbohy- 
drate. Some  babies  can  digest  maltose  better  than  lactose  or  starch, 
while  others  can  digest  lactose  or  starch  better  than  maltose.  The 
limit  of  carbohydrate  tolerance  is  extremely  variable  in  different 
babies,  and  cannot  be  categorically  stated.  In  general,  it  is  not 
advisable  to  give  more  than  7  per  cent  of  sugar  in  the  food  of  an 
infant,  nor  more  than  1.5  per  cent  of  starch  to  an  infant  under  one 
year  of  age.  At  times  an  extreme  degree  of  intolerance  toward  car- 
bohydrate in  general,  or  to  some  particular  sugar,  most  often  lactose, 
is  encountered. 

In  older  children  overfeeding  with  cane  sugar  is  the  most  common 
cause  of  carbohydrate  indigestion.  Candy  eating  is  the  most  frequent 
form  of  over-indulgence,  but  sometimes  the  eating  of  an  excessive 
amount  of  sugar  in  cocoa  or  on  cereals,  or  the  eating  of  too  much 
cake  or  dessert,  will  cause  indigestion  in  children  who  are  not  given 
much  candy.  Occasionally,  particularly  in  the  second  year,  indiges- 
tion is  caused  by  a  badly  regulated  diet,  in  which  there  is  a  relative 
excess  of  starchy  food.  When  babies  graduate  from  the  breast  or 
bottle,  the  first  articles  of  diet  added  are  the  starch-containing  foods. 
The  babies  often  like  these  foods  so  much  that  they  do  not  take 
enough  milk,  thus  increasing  the  carbohydrate  in  their  diet  at  the 
expense  of  the  fat  and  protein.  Frequent  eating  between  meals, 
especially  the  nibbling  of  crackers  and  cookies,  is  a  very  common  cause. 

SYMPTOMS.  In  Artificially-fed  Infants. — The  symptoms 
caused  by  a  relative  excess  of  carbohydrate  in  the  food  may  be  acute 
or  chronic.  They  are  due  to  the  fermentation  of  unabsorbed  carbo- 
hydrate. In  the  acute  cases  there  is  less  relation  between  dietary 
indiscretions  and  the  symptoms  than  in  chronic  cases.  It  is  difficult 
to  say  in  a  case  primarily  acute,  whether  the  symptoms  are  due  to 


Indigestion  from  an  Excess  of  Carbohydrate         427 

actual  overfeeding,  or  to  some  bacterial  condition  in  the  intestine 
which  causes  a  sudden  increase  in  fermentation.  In  cases  primarily 
acute,  bacteria  play  an  extremely  prominent  part,  and  the  border 
line  between  indigestion  from  overfeeding  with  carbohydrate,  and 
indigestion  with  fermentation  is  not  a  distinct  one.  It  therefore 
seems  best  to  describe  cases  of  intestinal  fermentation  which  are 
primarily  acute  under  the  heading  of  Indigestion  with  Fermentation, 
and  to  confine  the  clinical  description  of  Indigestion  from  an  Excess 
of  Carbohydrate  to  cases  which  are  chronic,  with  possible  acute 
exacerbations.  It  is  mainly  in  the  latter  class  of  cases  that  a  clear 
history  of  carbohydrate  excess  can  be  obtained. 

In  general  the  symptoms  are  the  same,  whatever  the  particular 
carbohydrate  which  is  in  relative  excess.  There  are,  however,  some 
symptoms  which  are  particularly  marked  with  excess  of  a  particular 
carbohydrate. 

The  general  symptoms  of  carbohydrate  indigestion  are  vomiting, 
abnormal  stools,  excessive  gas  formation,  and  loss  of  weight. 

The  vomiting  does  not  usually  occur  after  every  feeding.  It  does 
not  usually  take  place  right  after  feeding,  but  in  the  interval  be- 
tween feedings.  The  vomitus  is  acid  in  reaction,  and  may  have 
the  characteristic  odor  of  lactic,  acetic  or  butyric  acids.  Vomiting 
is  a  frequent  but  not  a  constant  symptom,  and  is  never  the  sole 
symptom,  as  it  sometimes  is  in  fat  indigestion,  but  is  always  accom- 
panied by  abnormal  stools. 

The  most  prominent  symptom  of  carbohydrate  indigestion  is  the 
passage  of  characteristic  stools.  In  mild  cases  the  stools  are  usually 
somewhat  looser  than  normal,  but  are  not  very  loose,  and  are  only 
slightly  increased  in  frequency.  In  more  severe  cases,  or  in  acute 
exacerbations,  the  stools  are  loose,  or  even  watery.  The  stools  are 
usually  green  in  color,  the  shade  varying  from  light  to  dark,  but  in 
indigestion  caused  by  the  maltose-dextrin  preparations,  they  are 
often  dark  brown.  They  may  contain  mucus.  They  are  very  acid, 
and  have  an  acid  odor;  sometimes  the  distinctive  odor  of  lactic, 
acetic,  succinic,  or  butyric  acid  can  be  distinguished.  These  acid 
discharges  are  very  irritating  to  the  buttocks,  and  excoriation  of 
the  buttocks  and  genitals  is  one  of  the  commonest  signs  of  indiges- 
tion from  an  excess  of  carbohydrate. 

Loss  of  weight  may  be  absent  in  the  mildest  cases.  It  is  marked 
in  the  severer  cases  in  which  the  stools  are  more  frequent  and  loose, 
and  is  very  rapid  in  acute  exacerbations  with   an   actual  diarrhea. 

Flatulence,  colic,  abdominal  distention,  and  the  passage  of  quan- 
tities of  gas  from  the  rectum,  are  symptoms  often  seen  in  carbohy- 
drate indigestion. 

Fever  and  intoxication  are  described  by  most  writers  as  occasional 
symptoms  of  indigestion  from  an  excess  of  carbohydrate.     I  have 


428  Diseases  of  the  Gastro-Enteric  Tract 

never  seen  a  case  in  which  I  could  attribute  these  symptoms  definitely 
to  an  excess  of  carbohydrate  in  the  food.  They  are  common  symp- 
toms of  indigestion  with  fermentation,  but  proof  is  lacking  that  in 
cases  showing  these  symptoms,  the  fermentation  involves  the  car- 
bohydrates, or  that  the  fever  is  due  to  the  carbohydrate  fermentation. 

The  follomng  are  the  main  peculiarities  of  the  symptoms  caused 
by  the  various  carbohydrates: — 

Lactose  is  the  sugar  most  likely  to  produce  acute  symptoms.  The 
stools  are  practically  always  green  and  very  irritating.  Flatulence 
and  colic  are  less  prominent. 

Cane  sugar  differs  from  lactose  mainly  in  being  less  likely  to  pro- 
duce acute  disturbance.  Babies  are  apt  to  gain  weight  on  cane 
sugar,  but  become  pale  and  flabby. 

The  maltose-dextrin  preparations  rarely  produce  acute  exacerba- 
tions. The  stools  are  often  dark  brown  rather  than  green,  and 
often  have  a  very  acrid  odor.  Vomiting  is  apt  to  be  more  promi- 
nent. The  vomitus  often  has  the  odor  of  butyric  acid.  Flatulence 
and  colic  are  more  common. 

Starch  produces  chronic  symptoms  only.  Vomiting  is  rarely  seen. 
The  stools  are  much  less  abnormal,  and  may  even  be  constipated, 
dry,  brown,  and  alkaline  in  reaction.  When  looser  they  are  brown, 
and  resemble  mucus  in  appearance.  They  are  only  slightly  acid, 
have  slight  if  any  acid  odor,  and  are  not  irritating  to  the  buttocks. 
The  principal  symptoms  of  indigestion  from  starch  are  colic,  which 
is  usually  very  pronounced,  flatulence,  and  abdominal  distention. 
The  babies  may  gain  in  weight,  but  are  flabby  and  pale.  That  the 
indigestion  is  due  to  starch  may  easily  be  recognized  by  the  examina- 
tion of  the  stools.  The  iodine  test  may  be  positive  macroscopically, 
and  is  always  recognizable  as  positive  microscopically. 

Indigestion  from  an  excess  of  carbohydrate  may  produce  the 
extreme  condition  of  malnutrition  described  as  Infantile  Atrophy. 
This  is  particularly  the  case  in  infants  who  have  suffered  from  fre- 
quent acute  attacks,  such  as  will  be  described  under  Indigestion  with 
Fermentation.  In  chronic  cases,  while  the  original  cause  may  be 
carbohydrate  indigestion,  when  infantile  atrophy  has  developed, 
there  is  usually  also  an  intolerance  of  fat. 

In  Older  Children. — The  type  of  disturbance  from  an  excess  of 
carbohydrate  in  older  children  has  been  formerly  described  under 
the  name  "Chronic  Duodenal  Indigestion,"  because  the  fermenta- 
tion occurs  mostly  in  the  duodenum,  and  upper  part  of  the  small 
intestine.  The  principal  subjective  symptoms  are  loss  of  appetite, 
abdominal  pain,  nausea,  particularly  in  the  morning,  cough,  and 
frontal  headache.  The  principal  objective  symptoms  are  bad  breath, 
coated  tongue,  bad  teeth,  pallor,  loss  of  weight,  prominent  abdomen, 
and  clay-colored  stools. 


Indigestion  from  an  Excess  of  Carbohydrate  429 

The  children  are  brought  to  the  physician  usually  without  suspicion 
on  the  part  of  the  parent  that  the  condition  is  connected  with  diges- 
tion, or  due  to  improper  feeding.  Some  cases  are  brought  on  account 
of  loss  of  appetite,  and  failure  to  gain  in  weight.  These  may  be  the 
only  symptoms.  When  in  addition  to  these  symptoms  pallor  and 
cough  are  present,  the  parents  often  suspect  tuberculosis.  Other 
cases  are  brought  for  "nervousness"  or  worms.  These  children  are 
nervous,  fretful,  subject  to  headaches,  pick  their  noses,  and  grind 
their  teeth  at  night.  More  than  half  the  cases  believed  by  parents 
to  be  suffering  from  worms  have  this  form  of  indigestion.  In  still 
other  cases  appendicitis  is  suspected,  because  abdominal  pain,  usu- 
ally referred  to  the  region  of  the  umbilicus,  is  the  most  prominent 
symptom,  and  is  often  associated  with  morning  nausea,  though 
rarely  with  vomiting.  The  symptoms  vary  greatly,  and  different 
combinations  are  present  in  each  case.  Loss  of  appetite  is  the  com- 
monest symptom;  nervousness,  abdominal  pain,  and  cough  stand  next. 

On  physical  examination  the  most  constant  sign  is  a  prominence 
of  the  abdomen  in  the  upper  portion.  Usually  the  tongue  is  coated; 
often  the  breath  is  bad,  and  the  teeth  decayed.  When  cough  is 
present,  examination  of  the  throat  will  reveal  enlargement  of  the 
lymphoid  follicles  of  the  posterior  pharyngeal  wall.  The  complexion 
is  pale,  sometimes  sallow,  but  the  blood  does  not  usually  show  a 
marked  reduction  in  hemoglobin.  The  patients  are  apt  to  be 
nervous,  fidgety,  very  bright  mentally,  and  take  a  pronounced  interest 
in  the  conversation  when  questions  of  diet  are  touched  upon. 

In  the  earlier  and  milder  stages  of  this  disease  the  stools  are  not 
characteristic.  In  typical  cases  they  are  clay-colored,  and  contain 
considerable  mucus.  In  pronounced  cases  they  consist  of  clay- 
colored  balls,  coated  with  mucus. 

In  Breast-fed  Infants. — Excess  of  sugar  in  breast  milk  is  a  very 
rare  condition.  The  symptoms  are  similar  to  those  caused  by  an 
excess  of  lactose  in  artificially-fed  infants,  but  are  milder  in  degree. 
The  principal  symptoms  are  sour  vomiting,  colic,  flatulence,  light- 
green  and  irritating  stools,  and  sometimes,  slight  loss  of  weight. 

DIAGNOSIS.  In  Infants. — The  diagnosis  is  based  mainly  upon 
the  clinical  picture,  which  is  more  characteristic  in  this  form  of  indi- 
gestion than  in  any  other.  The  acid  stools,  often  loose  and  green, 
with  the  occasional  sour  vomiting,  is  fairly  characteristic.  Irrita- 
tion of  the  buttocks  is  the  most  important  diagnostic  sign.  This 
may  occur  in  acute  exacerbations  of  indigestion  from  fat,  but  in 
such  cases  the  micro-chemical  examination  shows  excessive  soap,  and 
usually,  fatty  acids. 

The  diagnosis  is  often  greatly  strengthened  by  a  definite  history 
of  carbohydrate  overfeeding.     It  is  finally  confirmed  by  the  immediate 


430  Diseases  of  the  Gastro-Enteric  Tract 

improvement  which  takes  place  when  the  carbohydrate  in  the  food 
is  changed  in  kind,  or  reduced  in  amount. 

In  Older  Children. — The  diagnosis  in  older  children  is  easily 
made,  if  the  condition  is  not  forgotten.  Whatever  the  story  told 
by  the  mother,  whether  suggesting  tuberculosis,  appendicitis,  or 
nervousness,  the  physician  can  usually  by  questions  eUcit  other 
symptoms  characteristic  of  carbohydrate  indigestion.  Careful  and 
thorough  cross-examination  is  often  required  to  reveal  the  existence 
of  over-indulgence  in  sweets,  as  mothers  are  sometimes  so  bent  upon 
proving  that  the  child  has  some  serious,  obscure  disease,  that  they 
resent  inquiries  as  to  candy  and  cake,  and  conceal  or  minimize  the 
dietary  indiscretions.  Circuitous  paths  must  sometimes  be  employed 
in  questioning,  which  will  often  lead  to  pennies  received  from  a  neigh- 
bor for  running  errands,  or  to  visits  to  a  grand-parent.  Sometimes 
only  a  history  of  insufficient  milk,  too  much  starchy  food,  or  eating 
between  meals  can  be  obtained. 

Of  course  the  physician,  before  coming  to  a  final  conclusion,  must 
make  a  thorough  physical  examination,  in  order  that  some  more 
serious  condition,  such  as  tuberculosis  or  appendicitis,  may  not  be 
overlooked.  Usually  he  will  find  some  of  the  characteristic  signs 
of  carbohydrate  indigestion,  such  as  prominent  abdomen,  coated 
tongue,  or  bad  breath.  If  the  characteristic  clay-colored  stools  are 
present,  the  diagnosis  is  certain. 

PROGNOSIS. — Except  in  the  acute  types  to  be  described  under 
Indigestion  with  Fermentation,  the  prognosis  of  indigestion  from  a 
relative  excess  of  carbohydrate  is  good.  Artificially-fed  infants 
react  promptly  to  proper  treatment.  When  the  intolerance  involves 
one  particular  form  of  carbohydrate  only,  the  feeding  is  particularly 
easy.  Even  when  there  is  an  intolerance  of  all  forms  of  carbohydrate, 
the  necessary  reduction  of  the  carbohydrate  in  the  food  can  usually 
be  compensated  by  comparatively  shght  increases  in  the  fat  and 
protein.  Occasionally  difficulty  will  be  encountered  in  babies  having 
a  comparatively  low  fat  or  protein  tolerance,  in  whom  indigestion 
from  one  of  those  elements  may  be  produced.  Any  marked  degree 
of  intolerance  toward  fat  greatly  increases  the  difficulties  of  treat- 
ment. Occasionally  a  case  of  extreme  carbohydrate  intolerance  is 
encountered,  which  makes  the  quantities  of  fat  and  protein  required 
for  nutrition  too  much  for  the  child's  digestive  power.  In  these 
difficult  cases  the  prognosis  becomes  that  of  fat  or  protein  indigestion. 

The  power  of  digesting  carbohydrate  is  recovered  slowly,  weeks 
or  even  months  being  often  required.  It  is,  however,  recovered  more 
rapidly  than  the  power  of  digesting  fat. 

In  the  type  seen  in  older  children  the  prognosis  is  very  favorable. 
In  no  digestive  disturbance  is  so  prompt  and  satisfactory  a  response 


Indigestion  from  an  Excess  of  Carbohydrate  431 

to  proper  treatment  seen,  provided  that  the  directions  of  the  physi- 
cian are  faithfully  followed.  It  is  necessary,  however,  that  great 
care  in  the  supervision  of  the  diet  be  exercised  for  a  long  time,  if 
recurrence  is  to  be  prevented. 

TREATMENT.  In  Artificially-fed  Infants. — If  an  infant  is 
suffering  from  acute  symptoms,  with  an  actual  diarrhea,  it  is  advis- 
able to  begin  the  treatment  with  a  dose  of  castor  oil,  followed  by  a 
period  of  complete  rest  during  which  only  water  is  given. 

In  chronic  cases,  the  treatment  is  dietary  from  the  start.  The 
first  step  is  to  change  the  kind  of  extra  sugar  added  in  modifying 
the  milk.  If  milk  sugar  or  cane  sugar  has  been  used,  a  maltose- 
dextrin  preparation  should  be  substituted.  If  maltose  has  been  used 
previously,  the  change  should  be  to  lactose.  The  total  percentage 
of  carbohydrate  in  the  food  should  never  be  more  than  7%,  and  it  is 
usually  better  to  begin  with  5%  or  6%.  The  fat  may  be  2%,  2.5%, 
or  3%,  according  to  the  age  of  the  child,  and  the  protein  1%,  1.5%, 
or  2%.  If  changing  the  kind  of  sugar  used  relieves  the  symptoms, 
the  child  will  often  gain  weight  and  progress  normally  without  further 
change.  If  the  symptoms  are  relieved,  but  the  child  does  not  gain 
in  weight,  the  fat  and  protein  must  be  gradually  increased,  .25% 
at  a  time,  until  either  a  gain  in  weight  is  attained,  or  symptoms 
of  fat  or  protein  indigestion  develop. 

If  changing  the  kind  of  sugar  added  to  the  food  does  not  relieve 
the  symptoms,  there  is  an  intolerance  toward  sugar  in  general.  The 
amount  of  sugar  must  now  be  reduced  to  a  total  in  the  food  of  3% 
or  4%.  If  this  does  not  relieve  the  symptoms,  the  extra  carbohy- 
drate must  be  cut  out  entirely,  which  will  leave  in  the  food  only  the 
quantity  of  lactose  contained  in  the  milk  used  in  obtaining  the  re- 
quired protein  percentage.  If  symptoms  of  carbohydrate  indigestion 
still  persist,  it  is  evidence  of  an  extreme  degree  of  sugar  intolerance, 
and  must  be  treated  as  a  resistant  case. 

When,  after  the  quantity  of  sugar  in  the  food  is  reduced  sufficiently 
to  cause  a  relief  of  symptoms,  the  infant  is  unable  to  gain  in  w^eight, 
it  is  usually  a  sign  that  the  caloric  value  of  the  food  is  too  low.  The 
fat  and  protein  must  now  be  gradually  increased,  until  a  satisfactory 
gain  in  weight  is  attained.  If  the  extra  carbohydrate  has  been  cut 
out  entirely,  increasing  the  protein  will  necessarily  cause  a  correspond- 
ing increase  in  the  percentage  of  the  lactose  in  the  food,  as  more 
milk  is  used.  If  this  produces  symptoms  of  carbohydrate  indiges- 
tion, the  case  comes  into  the  class  of  resistant  cases.  If  increasing 
the  fat  and  protein  in  the  food  produces  symptoms  of  fat  or  protein 
indigestion  before  a  satisfactory  gain  in  weight  is  obtained,  the  case 
is  also  of  the  resistant  class,  but  its  further  management  is  guided  by 


432  Diseases  of  the  Gastro-Enteric  Tract 

the  principles  used  in  the  treatment  of  indigestion  from  excess  of 
fat  or  protein. 

Resistant  cases  of  indigestion  caused  purely  by  the  excess  of  car- 
bohydrate, are  those  in  which  the  quantity  of  lactose  contained  in 
the  amount  of  cow's  milk  needed  to  furnish  the  required  amount  of 
protein,  is  too  great  for  the  infant's  powers  of  digestion.  In  these 
cases  the  protein  is  best  given  in  the  form  of  precipitated  casein, 
which  permits  the  total  exclusion  of  lactose  for  the  time  being.  (See 
Di\dsion  on  Feeding.)  Such  a  formula  as  fat  2.00% — -sugar  0% — 
protein  1.5%  to  3.5%  can  thus  be  given.  Later  a  maltose-dextrin 
preparation  may  be  gradually  added  to  this  mixture,  raising  the 
sugar  percentage  1%  at  a  time. 

Sometimes  in  babies  showing  marked  evidences  of  carbohydrate 
indigestion,  time  will  be  saved  if  the  infants  are  put  at  once  on 
lactic  acid  milk,  which  is  comparatively  low  in  lactose  and  high  in 
protein,  or  on  a  precipitated  casein  mixture,  in  which  the  carbohy- 
drate may  be  made  still  lower,  or  on  a  combination  of  the  two  (albu- 
min milk).  This  may  allow  more  protein  to  be  given  at  the  start, 
without  the  production  of  indigestion.  In  the  resistant  cases  in 
which  fat  or  protein  indigestion  complicate  the  efforts  to  treat  indi- 
gestion from  sugar,  this  same  measure  is  the  first  which  should  be 
employed. 

In  cases  which  have  reached  a  condition  of  extreme  malnutrition, 
and  present  the  picture  of  Infantile  Atrophy,  no  time  should  be 
wasted  with  artificial  feeding,  if  human  milk  can  be  obtained. 

The  Type  Seen  in  Older  Children. — In  this  essentially  chronic 
type,  if  the  dietary  indiscretion  has  been  over-indulgence  in  cane 
sugar,  this  food  element  must  be  whoUy  excluded  from  the  diet. 
Parents  must  be  told  that  the  children  are  to  have  no  candy  at  all, 
and  no  sugar  in  or  upon  any  article  of  food.  Starches  must  not  be 
excluded,  but  in  marked  cases,  they  must  be  reduced  to  a  minimum. 
The  diet  should  consist  of  milk,  cereal  without  sugar,  meat  soups, 
meat,  fish,  eggs,  bread,  and  green  vegetables.  The  only  dessert 
allowed  should  be  fruit  cooked  without  sugar.  The  green  vegetables, 
and  those  low  in  starch,  such  as  spinach,  asparagus,  cauliflower,  and 
string  beans  are  preferable  to  the  starchy  vegetables  such  as  peas 
and  lima  beans.  Very  little  potato  should  be  allowed  in  mild  cases, 
and  none  in  severe  ones.  If  the  child  is  too  young  for  so  varied  a 
diet,  the  diet  appropriate  to  its  age  should  be  modified  upon  the 
same  principle — exclusion  of  sugar,  and  limitation  of  starch.  If  the 
symptoms  apparently  have  been  caused  not  by  an  excess  of  sugar, 
but  by  an  improper  balance  between  starch  and  the  other  food  ele- 
ments, the  physician  should  order  a  reduction  in  the  amount  of 
starch-containing  food,  and  see  that  the  full  quantity  of  milk  appro- 


Indigestion  from  an  Excess  of  Protein  433 

priate  to  the  diet  of  a  child  of  that  age  be  given.  Also,  whatever 
proteins  and  fats  are  permitted  by  the  age  of  the  child  should  be  given. 

It  is  essential  that  eating  between  meals  be  absolutely  prohibited. 
The  "piece  of  cracker"  and  even  the  "drink  of  milk"  are  harmful. 

The  chief  difhculty  encountered  in  carrying  out  this  treatment  is 
refusal  on  the  part  of  the  child  to  eat.  A  child  of  two  to  four  years 
is  an  adept  at  bullying  its  mother  into  giving  what  it  wants.  Firm- 
ness is  required  on  the  part  of  the  mother.  She  should  keep  putting 
before  the  child  at  meal  times  what  it  should  have,  and  should  neither 
coax  the  child,  nor  show  any  notice  of  whether  it  eats  or  not.  If  at 
any  time  between  meals  the  child  complains  of  being  very  hungry, 
the  mother  must  not  be  moved  by  any  tears  or  entreaties  to  give  it 
food.  Finally  the  child  will  always  yield,  and  the  battle  is  won, 
but  if  the  mother  once  gives  in,  the  difficulty  will  be  endless. 

The  treatment  of  this  form  of  chronic  indigestion  is  much  helped 
by  the  giving  of  tincture  of  nux  vomica  before  meals,  in  doses  usually 
from  one  to  five  minims,  according  to  the  age  of  the  child.  Consti- 
pation, if  present,  must  be  combatted  by  appropriate  treatment. 

In  Breast-fed  Infants. — The  symptoms  may  be  temporarily  re- 
lieved by  giving  the  baby  a  Httle  boiled  water  immediately  before 
each  nursing,  and  shortening  the  nursing  time  a  Httle.  If  the  mother 
has  been  eating  an  excessive  quantity  of  sugar,  this  should  be  cor- 
rected. If  she  has  not  been  eating  too  much  sugar,  it  is  probable 
that  she  has  been  eating  too  much  in  general.  If  the  total  amount 
of  the  diet  is  reduced,  and  if  she  takes  more  exercise  in  the  open 
air,  the  excessive  sugar  in  her  milk  will  quickly  disappear. 

PROBLEMS  AND  RESEARCH.— The  question  of  how  much 
carbohydrate  is  assimilated  is  still  unsolved.  There  are  many  un- 
solved problems  in  carbohydrate  metaboHsm,  for  the  solution  of 
which  we  must  look  to  future  metabolism  work.  The  most  import- 
ant practical  problems  in  carbohydrate  indigestion  are  connected 
with  the  subject  of  intestinal  bacteriology  and  fermentation.  These 
will  be  discussed  at  greater  length  under  the  heading  of  Indigestion 
with  Fermentation. 

INDIGESTION  FROM  EXCESS  OF  PROTEIN 

DIGESTION  AND  METABOLISM  OF  PROTEIN.— A  summary 
of  the  known  facts  as  to  the  digestion  and  absorption  of  protein  is 
necessary  for  an  understanding  of  the  principles  of  infant  feeding, 
and  of  the  effects  of  a  relative  excess. 

Role  of  the  Protein. — Protein  is  the  only  food  element  abso- 
lutely essential  not  only  to  the  growth  of  the  child,  but  also  to  the 
continuance  of  hfe  itself.  Nitrogen  is  the  chemical  element  used  in 
the  formation  of  new  tissue,  and  in  the  replacement  of  the  daily 
28 


434  Diseases  of  the  Gastro-Enteric  Tract 

wear  in  the  tissues  of  the  body,  and  protein  is  the  only  food  element 
which  contains  nitrogen.  No  matter  how  great  the  number  of  calo- 
ries, protein  cannot  be  replaced  by  other  food  elements.  Every  baby 
has  a  minimum  daily  protein  requirement,  which  varies  with  the 
individual,  particularly  in  sick  babies,  but  which  in  general  lies 
between  1.5  and  2  grams  per  kilogram  of  the  body  weight. 

The  adult  needs  protein  only  for  the  repair  of  tissue  waste ;  the  baby 
needs  protein  not  only  for  the  repair,  but  for  growth.  In  the  adult 
the  demand  for  maintenance  of  the  nitrogen  equilibrium  is  powerful, 
but  not  so  imperative  as  the  demand  for  fuel,  and  if  the  food  is  in- 
sufficient in  caloric  value,  protein  will  be  sacrificed  and  nitrogen  will 
be  lost.  It  is  not  so  with  the  growing  child.  The  imperative  demand 
is  for  growth,  and  if  the  food  is  insufficient  in  caloric  value,  the  baby 
will  continue  to  utihze  protein  for  growth,  will  retain  nitrogen  and 
sacrifice  other  tissue  elements  for  fuel  as  long  as  possible.  Thus 
an  infant,  at  the  expense  of  its  general  nutrition,  will  grow  in  length 
while  losing  in  weight. 

Protein  can,  however,  be  used  for  energy  production.  Its  caloric 
value  is  the  same  as-  that  of  the  carbohydrate,  but  only  between 
one-quarter  and  one-third  is  given  off  as  heat.  Consequently,  pro- 
tein is  very  uneconomical  as  a  fuel,  and  the  products  of  its  combus- 
tion throw  a  difficult  burden  on  the  organs  of  elimination.  It  is 
probable  that  the  products  of  rapid  protein  combustion  may  some- 
times be  toxic.  Under  normal  conditions,  the  role  of  protein  as  a 
source  of  energy  is  small. 

The  mineral  salts  in  the  food  are  also  necessary  for  the  building 
up  of  the  body  tissues.  They  are  necessary  for  the  proper  retention 
of  nitrogen,  and  the  salt  content  of  the  food  probably  has  a  very 
marked  influence  on  the  storage  of  nitrogen.  The  influence  of  the 
carbohydrate  in  the  food  on  the  retention  of  nitrogen  has  been  men- 
tioned in  connection  with  the  metabolism  of  carbohydrate.  In  spite 
of  its  high  caloric  value,  fat  does  not  spare  nitrogen. 

Digestion  of  the  Protein. — The  ferments  necessary  for  the  diges- 
tion of  the  protein  are  all  present  and  active  at  birth.  The  pepsin 
of  the  stomach,  in  the  presence  of  hydrochloric  acid,  spHts  the  pro- 
tein into  albumoses  and  peptones.  The  trypsin  of  the  pancreatic 
juice,  and  the  erepsin  of  the  small  intestine  further  split  these  prod- 
ucts into  polypeptids,  and  finally  into  amino-acids. 

Absorption  and  Metabolism  of  the  Protein. — The  protein  is 
absorbed  in  the  form  of  amino-acids,  circulates  in  the  blood  in  that 
form,  and  is  reconstructed  by  the  body  cells  into  the  various  comph- 
cated  constituents  of  the  tissues.  These  are  disintegrated  as  a  result 
of   cellular  metabolism,   and   are   excreted   chiefly  by   the  kidneys. 


Indigestion  from  an  Excess  of  Protein  435 

There  are  a  number  of  end  products,  the  most  important  of  which 
are  urea  and  ammonia. 

Under  normal  conditions  the  protein  of  the  food  is  almost  all 
broken  down  and  absorbed,  the  nitrogen  of  the  feces  being  derived 
almost  entirely  from  bacteria. 

The  weight  of  experimental  evidence  is  in  favor  of  the  conclusion 
that  the  retention  of  nitrogen  is  equally  good  in  breast-fed  and  arti- 
ficially-fed infants,  and  also  equally  good  in  sick  and  healthy  infants. 
Consequently,  inabiHty  to  digest  sufficient  protein,  if  the  amount 
needed  be  given  in  the  food,  is  not  a  factor  in  the  nutritional  disturb- 
ances of  infancy. 

Effect  of  an  Excess  of  Protein. — There  is  no  conclusive  evi- 
dence that  the  giving  of  an  excess  of  protein  produces  any  injurious 
effect  upon  metabolism  through  excessive  absorption.  It  is  probable 
that  in  the  adult  excessive  protein  absorption  can  produce  an  injuri- 
ous effect,  but  in  the  child,  the  excess  is  either  not  digested  and  ab- 
sorbed, or  is  normally  utilized. 

The  principal  effect  of  excessive  protein  in  the  food  is  confined 
to  the  gastro-intestinal  canal.  The  disturbance  is  chiefly  caused  by 
the  casein.  When  the  quantity  of  casein  given  in  the  food  is  too 
great,  the  curds  formed  in  the  stomach  by  the  action  of  the  rennin 
are  large  and  tough,  and  difficult  of  digestion.  The  undigested 
curds  may  act  as  irritants  to  the  gastric  or  intestinal  mucous  mem- 
brane, causing  increased  peristaltic  action  and  vomiting. 

It  is  possible  that  an  excessive  amount  of  whey-protein  may  cause 
a  disturbance  of  digestion.  If  so,  we  know  little  about  the  nature 
of  the  disturbance  produced.  Foods  containing  an  excessive  amount 
of  whey-protein,  contain  also  an  excessive  amount  of  lactose  and  salts. 
The  digestive  disturbance  seen  in  such  babies  usually  takes  the  clinical 
type  of  carbohydrate  or  fat  indigestion,  and  in  most  instances  it  is 
probably  caused  by  lactose  or  salts.  It  is  possible  also  that  the 
whey-protein  is  a  particularly  favorable  culture  medium  for  some 
of  the  intestinal  organisms  belonging  to  the  putrefactive  group,  and 
this  may  explain  some  of  the  disturbances  seen  in  babies  fed  on  whey 
mixtures.  The  disturbances  will  be  described  under  Indigestion  with 
Fermentation. 

Protein  and  Anaphylaxis. — The  disturbances  sometimes  caused 
by  cow's  milk  have  been  attributed  to  the  foreign  protein  contained 
in  that  food.  The  connection  between  cow's  milk  and  anaphylaxis 
has  been  an  interesting  field  for  speculation  and  experiment.  There 
is  no  doubt  that  occasionally  a  baby  is  seen  who  has  an  idiosyncrasy 
toward  cow's  milk,  reacting  in  a  manner  which  makes  it  very  prob- 
able that  the  disturbance  is  an  anaphylactic  phenomenon  caused  by 
the  cow's  milk  protein. 


436  Diseases  of  the  Gastro-Enteric  Tract 

ETIOLOGY.^ — Indigestion  from  excess  of  protein  in  the  food 
occurs  both  in  breast-fed  and  in  artificially-fed  infants.  It  is  the 
only  form  of  digestive  disturbance  seen  in  breast-fed  infants  which 
is  at  all  common.  The  protein  in  breast  milk  is  often  excessive 
during  the  early  part  of  lactation.  The  probable  cause  of  this  excess 
is  that  the  mother  has  not  yet  resumed  her  normal  life,  and  the 
equilibrium  of  her  milk  has  not  become  established.  Most  of  the 
causes  exercising  a  deleterious  effect  upon  lactation  are  more  apt 
to  influence  the  protein-content  of  the  milk  than  that  of  the  other 
food  elements.  Such  factors  as  anxiety,  nervousness,  fatigue,  or 
lack  of  sufficient  exercise,  may  all  cause  an  increase  in  the  percentage 
of  protein  in  the  milk.  Whether  or  not  the  excessive  protein-content 
produces  symptoms  of  indigestion  in  the  baby,  depends  upon  the 
digestive  power  of  the  individual  infant.  Both  in  breast-fed  and 
in  artificially-fed  infants,  protein  indigestion  is  most  apt  to  occur  in 
the  earlier  months,  when  the  digestive  power  is  relatively  undeveloped. 

In  babies  who  are  fed  on  cow's  milk  mixtures,  if  the  principles 
of  artificial  feeding  are  followed,  and  if  ordinary  modifications  are 
used,  indigestion  from  an  excess  of  protein  is  comparatively  rare. 
When  the  milk  is  not  properly  modified,  and  when  consequently  an 
excessive  quantity  of  protein  is  actually  given,  indigestion  may  be 
produced,  especially  in  the  younger  infants.  Symptoms  referable 
to  protein  indigestion  are  often  seen  in  babies  whose  digestive  power 
has  been  injured  by  overfeeding,  or  in  babies  who  are  given  an  exces- 
sive quantity  of  protein  to  compensate  for  a  difficulty  in  digesting 
fat  and  carbohydrate. 

SYMPTOMS.  In  Breast-fed  Infants. — The  symptoms  seen  in 
breast-fed  infants  are  chiefly  vomiting,  colic,  and  abnormal  stools. 
Vomiting  is  comparatively  uncommon;  when  it  does  occur,  it  usually 
takes  place  shortly  after  nursing.  The  vomitus  is  not  of  sour  odor, 
and  does  not  contain  the  tough  curds  seen  in  babies  who  are  fed  on 
cow's  milk.  Colic  and  flatulence,  on  the  other  hand,  are  almost 
constant  symptoms,  and  are  often  very  annoying.  The  stools  are 
usually  increased  in  number  and  are  looser  than  normal.  Instead 
of  the  golden-yellow  characteristic  of  the  stools  of  the  normal  breast- 
fed infant,  the  color  in  indigestion  from  protein  is  a  brownish-yellow, 
and  sometimes  it  is  green.  Fine  curds  and  considerable  mucus  are 
often  present.  In  reaction  the  stools  are  usually  alkaline,  but  may 
be  slightly  acid,  they  are  not  irritating  to  the  buttocks.  The  odor 
of  the  stools  is  not  characteristic.  The  weight  curve  may  be  sta- 
tionary, or  there  may  be  a  slight  loss.  Often,  however,  a  baby  even 
with  marked  symptoms  of  protein  indigestion,  will  continue  to  gain 
in  weight. 

In  Artificially-fed  Infants. — The  same  general  symptoms  are 


Indigestion  from  an  Excess  of  Protein  437 

seen  in  artificially-fed  infants,  namely,  vomiting,  colic,  abnormal 
stools,  and  loss  of  weight.  Vomiting  is  much  more  common;  it  is 
not  seen  in  every  case,  but  it  is  usually  present  in  cases  severe  enough 
to  produce  much  disturbance  of  nutrition.  The  vomiting  is  apt  to 
occur  very  shortly  after  feeding,  and  the  vomitus  usually  contains 
large  curds,  which  may  be  soft,  or  very  tough  and  leathery.  The 
vomitus  has  very  little  if  any  odor.  Colic  and  eructations  of  gas 
are  usually  present,  and  are  often  quite  marked. 

In  the  majority  of  cases  the  number  of  stools  is  not  increased,  and 
their  appearance  is  normal,  except  for  the  presence  of  large  tough 
curds.  In  some  cases  the  stools  are  slightly  increased  in  number, 
and  are  looser  in  consistency,  with  a  brownish  color  and  a  pecuUar 
sticky  appearance  when  manipulated.  The  stools  of  protein  indi- 
gestion are  usually  alkaline  in  reaction.  Their  odor  is  musty  or 
slightly  foul. 

Loss  of  weight  in  protein  indigestion  is  usually  comparatively 
sHght.  In  the  type  characterized  only  by  the  presence  in  the  stools 
of  large  casein  curds,  nutrition  is  usually  not  disturbed  at  all. 

DIAGNOSIS.  In  Breast-fed  Infants. — The  disturbance  caused 
by  excessive  protein  in  breast  milk  is  difficult  to  distinguish  from  the 
disturbance  caused  by  irregular  or  too  frequent  nursing,  on  the  basis 
of  the  chnical  symptoms  alone.  When  a  breast-fed  baby  is  nursed 
properly  at  regular  intervals  and  still  has  symptoms  of  indigestion, 
the  probability  is  that  it  is  the  protein  which  is  excessive  in  the 
breast  milk.  Fat  indigestion  is  excluded  by  the  micro-chemical 
examination  of  the  stools,  and  carbohydrate  indigestion  by  the 
absence  of  acid,  irritating  discharges. 

In  Artificially-fed  Infants,  the  most  important  diagnostic  symp- 
toms are  the  vomiting  of  large  curds,  the  passage  of  large,  tough 
curds  in  the  stools,  or  the  existence  of  brownish,  sticky,  musty  fecal 
discharges.  Indigestion  from  an  excess  of  fat  is  excluded  by  the 
absence  of  excessive  soap  in  the  discharges;  and  carbohydrate  indi- 
gestion is  excluded  by  the  absence  of  characteristic  acid,  irritating 
movements.  The  most  difficult  form  of  indigestion  to  exclude  is 
that  caused  by  an  excess  of  food  as  a  whole.  When  a  reduction  in 
the  total  amount  of  food  given  is  not  followed  by  clinical  improve- 
ment, and  when  the  symptoms  of  fat  and  carbohydrate  indigestion 
are  absent,  it  may  be  concluded  that  the  protein  is  the  food  element 
at  fault. 

PROGNOSIS. — In  breast-fed  babies  the  prognosis  is  very  favor- 
able, provided  that  the  cause  of  the  excess  of  protein  can  be  removed. 
Proper  regulation  of  the  hygiene  of  lactation  will  remove  the  cause 
in  the  majority  of  cases.  In  some  cases,  the  mother's  mode  of  life 
cannot  be  properly  regulated,  and  in  other  cases  there  is  so  marked 


438  Diseases  of  the  Gastro-Enteric  Tract 

an  abnormality  of  secretion  that  the  protein  in  the  milk  will  con- 
tinue in  excess  in  spite  of  proper  regulation  of  the  mother's  life. 
In  these  cases  the  prognosis  becomes  that  of  artificial  feeding  in 
general. 

In  artificially-fed  babies  the  prognosis  of  a  primary  protein  indi- 
gestion is  very  good.  The  resources  of  artificial  feeding  directed 
toward  making  the  casein  of  cow's  milk  more  digestible  are  so  numer- 
ous that  good  results  can  usually  be  obtained  by  the  use  of  one  of 
them.  It  is  only  when  protein  indigestion  is  caused  by  an  effort  to 
compensate  for  some  other  digestive  difficulty  by  increasing  the 
protein  that  the  prognosis  becomes  more  doubtful. 

TREATMENT.  In  Breast-fed  Infants.— The  breast  milk 
should  be  temporarily  diluted  by  giving  the  baby  one  or  two  tea- 
spoonfuls  each  of  boiled  water  and  lime  water  immediately  before 
each  nursing.  The  mother's  diet  and  mode  of  life  should  be  regu- 
lated in  accordance  with  the  principles  described  in  the  Division  on 
Feeding.  She  should  be  prevented  from  overeating,  from  fatigue, 
and  from  taking  insufficient  exercise,  and  should  be  reheved  as  far 
as  possible  from  worry  and  anxiety.  Increasing  the  length  of  the 
intervals  between  the  nursings  will  often  prove  of  marked  assistance. 

In  Artificially-fed  Infants. — In  the  earlier  months  of  infancy 
the  measure  of  milk  modification  best  fitted  to  meet  difficulty  in 
digesting  the  protein  is  the  use  of  a  whey  mixture.  The  fat  and 
carbohydrate  may  be  ordered  in  percentages  adapted  to  the  age  of 
the  infant,  usually  about  2%  fat,  and  6%  total  carbohydrate.  The 
maximum  whey-protein  percentage  and  minimum  casein  percentage 
possible  should  be  used — usually  about  .80%  whey-protein  and  .40% 
casein.  If  centrifugal  cream  from  a  milk  laboratory  is  used,  the 
casein  percentage  may  be  reduced  still  lower.  This  treatment  is 
particularly  successful  in  cases  characterized  chiefly  by  the  vomiting 
of  large  curds.  In  older  infants  the  first  step  is  reduction  in  the 
amount  of  protein  in  the  food,  care  being  taken  not  to  diminish  it 
below  the  minimum  protein  requirement  of  1.5  to  2  grams  per  kilo- 
gram of  body  weight.  If  this  does  not  relieve  the  symptoms,  a  whey 
mixture  may  be  tried  in  older  infants  also. 

If  this  method  of  modifying  the  milk  is  not  successful,  the  further 
treatment  depends  somewhat  upon  whether  the  chief  symptom  is 
the  vomiting  of  large  curds,  the  passage  of  large  curds  in  the  stools, 
or  the  passage  of  brown,  sticky,  musty  stools. 

When  vomiting  is  the  chief  symptom  the  physician  should  try  the 
addition  of  one  of  the  alkalies, — lime  water,  sodium  bicarbonate,  or 
sodium  citrate, — to  the  milk  modification.  These  alkalies  should  be 
added  in  the  amounts  sufficient  to  prevent  the  precipitation  of  the 
casein  in  the  stomach, — for  lime  water  50%  of  the  milk  and  cream  ^ 


Indigestion  from  an  Excess  of  Protein  439 

for  sodium  bicarbonate  1.7%  of  the  milk  and  cream,  for  sodium  citrate 
0.4%  of  the  milk  and  cream.  The  alkalies  may  be  added  either  to 
whey  mixtures  or  to  mixtures  containing  unmodified  protein.  Usu- 
ally with  the  alkalies  it  is  best  to  use  the  latter.  The  amount  of 
protein  should  not  be  below  the  average  normal  minimum  protein 
requirement.  If  the  alkalies  are  not  successful,  the  physician  should 
try  the  addition  of  starch  in  the  amount  of  0.75%  of  the  milk  and 
cream.  If  this  is  ineffective,  he  may  try  giving  the  protein  in  the 
form  of  precipitated  casein,  or  in  lactic  acid  milk. 

When  the  chief  symptom  is  the  presence  in  the  stools  of  large 
casein  curds  the  following  methods  are  apphcable: — i.  Boiling  the 
milk.  2.  The  addition  of  starch  in  a  cereal  diluent.  3.  The  addition 
of  one  of  the  alkalies.  4.  The  giving  of  protein  in  the  form  of  pre- 
cipitated casein,  or  in  buttermilk,  or  in  a  combination  of  the  two 
(albumin  milk).  5.  Peptonization.  It  is  difficult  to  say  which  of 
these  measures  will  prove  most  effective  in  a  given  case.  In 
infants  over  sLx  months  old,  the  use  of  a  cereal  diluent  is  the  method 
of  choice,  and  if  this  is  not  completely  successful,  the  milk  may  be 
boiled  in  addition.  In  younger  infants,  boiling  should  be  tried  first, 
and  then  a  cereal  diluent  may  be  added.  If  these  measures  are 
unsuccessful,  the  alkahes  may  be  tried,  and  the  precipitated  casein 
methods  kept  for  a  last  resource.     Peptonization  is  rarely  required. 

In  the  type  characterized  by  loose,  brown,  musty  stools,  all  pro- 
tein should  be  excluded  from  the  food  for  a  period  lasting  from  24 
to  48  hours.     Casein  should  then  be  added  little  by  little. 

Resistant  cases  of  protein  indigestion  are  usually  not  encountered 
except  when  an  effort  is  being  made  to  treat  some  other  form  of 
indigestion  by  substituting  protein  for  whatever  food  element  is 
not  tolerated.  In  indigestion  from  excess  of  fat  particularly,  it  is 
often  necessary  to  give  a  large  amount  of  protein.  Vomiting  is  a 
most  prominent  symptom  in  these  resistant  cases,  and  is  usually 
difficult  to  treat,  because  prolonged  irritation  of  the  gastric  mucosa 
has  made  it  intolerant  toward  casein  precipitation.  These  cases  will 
tax  all  the  resources  enumerated  above  as  applicable  to  protein 
indigestion. 

PROBLEMS  AND  RESEARCH.— The  amount  of  research  work 
which  is  being  done  in  infantile  digestion  and  metabolism  in  general, 
is  so  enormous  that  it  is  difficult  to  indicate  particular  aspects  of 
the  subject  in  which  we  may  look  to  the  near  future  for  addition  to 
our  knowledge  which  shall  be  of  practical  value.  Among  the  un- 
settled questions  are  the  following: — i.  Can  the  feeding  of  excessive 
protein  produce  disturbance  of  metabolism  through  excessive  ab- 
sorption? 2.  Are  the  disturbances  in  digestion  which  are  often  seen 
in  babies  fed  on  whey  mixtures  due  to  the  whey-protein,  or  are  they 


440  Diseases  of  the  Gastro-Enteric  Tract 

due  to  lactose  or  salts?  3.  What  influence  does  the  feeding  of  exces- 
sive protein  have  upon  intestinal  bacteriology?  4.  What  role  does 
anaphylaxis  play  in  the  disturbance  seen  in  babies  fed  on  cow's  milk? 

In  connection  with  the  question  as  to  whether  excessive  protein 
absorption  can  cause  disturbance,  it  is  interesting  to  note  some 
experiments  of  Holt  and  Levene,  who  produced  fever  in  babies  by 
giving  a  (synthetic)  food  containing  6%  of  casein.  They  called 
attention  to  the  resemblance  between  this  fever  and  that  produced 
by  Vaughn,  by  the  parenteral  injection  of  protein.  Their  food, 
however,  contained  so  large  a  quantity  of  mineral  salts  that  it  is 
possible  that  the  salts  may  have  been  the  cause  of  the  fever. 

There  is  some  evidence  that  disturbances  of  digestion  in  babies 
fed  on  cow's  milk  may  be  an  anaphylactic  phenomenon.  Various 
experiments  have  shown  that  when  a  foreign  protein  is  introduced 
for  the  first  time  into  the  gastro-intestinal  canal  of  infants,  there 
is  a  reaction  in  the  body  similar  to  that  obtained  in  active  sensitiza- 
tion and  immunization.  The  present  stage  of  the  theory  is  that, 
in  very  young  babies,  or  in  sick  babies,  the  cow's  milk  protein  may 
pass  through  the  intestinal  wall  without  digestive  splitting,  and  may 
produce  the  sequence  of  sensitization  and  immunity.  The  relation 
of  this  phenomenon  to  the  disturbances  of  digestion  is  not  very 
definitely  established,  except  in  the  peculiar  instance  of  cases  showing 
individual  idiosyncrasy  toward  cow's  milk,  which  are  accompanied 
by  such  symptoms  as  urticaria. 

INDIGESTION   FROM   AN   EXCESS   OF   MINERAL   SALTS 

PROBLEMS  AND  RESEARCH.— There  is  no  form  of  indiges- 
tion which  has  been  definitely  associated  with  an  excess  of  salts  in 
the  food.  The  important  part  played  by  the  salts  in  metaboHsm  is 
well  known,  and  it  is  probable  that  they  play  a  part  in  the  digestion 
and  metabolism  of  the  other  food  elements.  It  is  possible  that  a 
relative  excess  of  salts  may  be  a  contributing  factor  in  the  etiology 
of  indigestion  from  fat,  carbohydrate,  or  protein.  It  is  even  possible 
that  in  certain  cases  the  primary  injury  to  the  digestive  power  may 
come  from  an  excess  of  salts,  but  that  we  are  only  able  to  recognize 
the  disturbance  when  manifested  in  inability  to  digest  some  other 
food  element.  Present  day  investigation  is  concerned  with  just  such 
problems  as  the  influence  of  the  salts  in  digestion,  and  their  role  in 
metaboKsm.  Advances  in  the  knowledge  of  this  subject  are  to  be 
looked  for  in  the  near  future,  and  therefore  a  review  of  some  of  the 
leading  known  facts  about  salt  metabolism  is  advisable  in  any  dis- 
cussion of  the  subject  of  indigestion. 

Role  of  the  Salts. — The  role  of  the  salts  in  metabolism  is  similar 
to  that  of  protein,  namely,  the  repair  of  tissue  waste,  and  the  build- 


Indigestion  from  an  Excess  of  Salts  441 

ing  of  the  new  tissue  required  for  growth.     The  salts  are  consequently 
essential  not  only  for  growth,  but  for  the  continuance  of  life  itself. 

Metabolism  of  the  Salts. — Both  human  milk  and  cow's  milk 
contain  a  sufficient  amount  of  all  the  salts  needed  for  normal  meta- 
boUsm  in  a  growing  infant,  except  iron.  Both  are  deficient  in  iron, 
and  anemia  would  quickly  develop  in  an  infant  were  it  not  for 
the  iron  stored  in  the  liver  during  fetal  hfe.  The  part  played  by 
the  salts  in  digestion  is  very  complicated,  and  very  little  is  known  of 
it.  They  are  absorbed  from  the  intestine,  and  may  be  re-excreted 
into  the  digestive  canal;  the  digestive  juices  contain  salts.  There 
are  undoubtedly  reactions  between  the  salts  and  the  organic  food 
elements,  but  these  are  very  complicated,  and  little  is  known  of 
the  subject. 

The  differences  in  the  salt  content  of  cow's  milk  and  human  milk 
have  been  discussed  in  the  division  on  Feeding.  It  is  known  that 
cow's  milk  contains  more  ash  than  human  milk,  and  in  what  salts 
the  excess  lies.  It  is  known  that  the  breast-fed  infant  absorbs  about 
80%  of  the  salt  content  of  its  food  while  the  artificially-fed  infant 
absorbs  from  43%  to  78%.  A  larger  amount  of  the  salts  is  retained 
in  the  early  months  of  infancy  when  growth  is  most  active,  than  in 
the  later  months.  Salt  retention  is  better  in  breast-fed  than  in 
artificially-fed  infants,  in  the  former,  according  to  Hoobler,  between 
40%  and  50%,  in  the  latter  between  0%  and  43%.  It  is  probable 
that  the  low  retention  of  salts  sometimes  seen  in  artificially-fed  in- 
fants, is  due  to  indigestion,  as  it  is  known  from  Talbot  and  Hill's 
experiments  that  in  certain  conditions  with  diarrhea  there  may  be 
an  actual  loss  of  salts  from  the  body. 

The  salts  are  ehminated  partly  in  the  urine  and  partly  in  the 
feces.  About  one-third  has  been  found  to  be  ehminated  through 
the  feces  when  human  milk  is  the  food,  while  one-half  is  thus  elim- 
inated with  cow's  milk. 

Disturbances  of  Salt  Metabolism. — It  is  known  that  in  nutri- 
tional disturbances  there  are  very  marked  changes  in  the  metabolism 
of  the  salts.  These  may  vary  from  slight  diminution  of  retention 
to  such  excessive  loss  of  the  alkaline  salts  that  a  relative  acidosis 
may  develop. 

Problems  Awaiting  Solution. — Knowing  that  the  salts  are 
concerned  in  digestion,  we  assume  that  a  relative  excess  can  cause  a 
disturbance  of  digestion.  There  is,  however,  very  little  definite 
evidence.  We  know  that  a  large  quantity  of  sodium  chloride  given 
to  a  baby  may  produce  a  rise  of  temperature,  but  only  when  there 
is  also  produced  some  disturbance  of  digestion,  and  therefore  no 
definite  effect  of  the  excess  of  salt  is  proved.  The  problems  are, 
can  an  excess  of  salts  produce  a  primary  disturbance  of  digestion, 


442  Diseases  of  the  Gastro-Enteric  Tract 

and  what  influence  does  an  excess  have  on  the  digestion  of  the  various 
food  elements?  Furthermore,  what  are  the  more  compUcated  dis- 
turbances of  salt  metabolism  seen  in  severe  nutritional  disturbances? 
Practically,  in  any  obstinate  form  of  indigestion,  in  a  baby  fed 
on  cow's  milk,  we  can  try  the  effect  of  diminishing  the  salts. 

INDIGESTION  WITH  FERMENTATION 

(Fermental  Diarrhea) 

This  is  a  condition  in  which  the  most  prominent  disturbance  of 
the  digestive  function  is  caused  by  excessive  bacterial  fermentation 
in  the  intestinal  contents.  The  term  fermentation  is  used,  not  in 
the  limited  sense  in  which  it  is  sometimes  used  to  describe  carbohy- 
drate fermentation  only,  but  in  its  broad  sense  to  describe  all  the 
results  of  excessive  bacterial  growth  and  activity. 

As  bacteria  are  normal  inhabitants  of  the  intestinal  canal,  there 
must  at  all  times  be  fermentation  taking  place  there.  The  bacteria 
live  upon  the  same  food  as  their  human  host.  A  certain  proportion 
of  the  food  ingested  is  not  absorbed,  but  remains  behind  to  support 
the  microscopic  inhabitants  of  the  intestine.  We  have  already  seen, 
in  considering  the  subject  of  indigestion  from  an  excess  of  carbohy- 
drate, that  Nature  furnishes  in  the  normal  food  of  infants  an  excess 
of  a  fermentable  carbohydrate  which  is  comparatively  slowly  split 
and  absorbed.  This  leaves  behind  sufficient  sugar  to  support  bac- 
terial life,  and  is  probably  a  condition  necessary  for  the  maintenance 
of  a  normal  intestinal  bacteriology.  It  is  probable  that  the  amounts 
of  the  food  elements  which  are  not  digested  and  absorbed  must  be 
properly  balanced,  one  against  another,  in  order  that  normal  condi- 
tions of  fermentation  shall  prevail.  When  there  is  indigestion,  this 
balance  is  disturbed,  and  consequently  the  conditions  of  bacterial 
fermentation  in  the  intestine  become  abnormal.  It  is  probable 
therefore  that  a  certain  amount  of  abnormal  fermentation  accompanies 
many  cases  of  indigestion.  If  this  is  the  case,  what  is  the  distinction 
between  simple  indigestion  and  indigestion  with  fermentation? 

In  simple  indigestion  abnormal  fermentation  is  only  a  contribut- 
ing factor  in  producing  the  symptoms  of  disease.  It  is  not  extremely 
excessive,  and  does  not  dominate  the  clinical  picture.  The  relation 
of  the  symptoms  of  indigestion  to  relative  overfeeding,  whether  with 
food  as  a  whole,  or  with  one  of  the  individual  food  elements,  is  a 
prominent  feature  of  simple  indigestion.  In  indigestion  with  fer- 
mentation, abnormal  bacterial  activity  is  so  excessive  that  it  pro- 
duces the  symptoms  which  dominate  the  clinical  picture.  The  rela- 
tion of  the  occurrence  of  disease  symptoms  to  a  relative  overfeeding 
with  food  as  a  whole,  or  with  any  one  food  element,  is  usually  not 
obvious.     The  disease  appears  primarily  as  a  bacterial  condition, 


Indigestion  with  Fermentation  443 

and  the  manner  of  its  occurrence  suggests  a  variety  of  concurrently 
acting  causes,  among  which  dietary  indiscretion  does  not  necessarily 
play  the  chief  part. 

Indigestion  with  fermentation  is  not  the  only  disturbance  pro- 
duced in  the  intestinal  canal  by  bacteria.  There  is  another  con- 
dition, which  will  be  described  under  the  name  of  Infectious  Diar- 
rhea. The  distinction  between  these  two  conditions  is  a  somewhat 
arbitrary  one,  since  both  are  caused  by  bacteria.  In  indigestion 
with  fermentation  the  organisms  concerned  all  belong  to  the  group 
of  saprophytes,  and  are  capable  of  producing  the  same  fermentation 
outside  the  body.  In  infectious  diarrhea  most  of  the  organisms  con- 
cerned are  true  parasites,  requiring  a  host  for  their  development. 
In  indigestion  with  fermentation  the  bacteria  do  not  attack  nor 
seriously  injure  the  tissues  of  the  host;  they  live  on  the  intestinal 
contents,  and  any  lesions  produced  in  the  intestine  are  comparatively 
slight,  due  to  the  irritation  of  their  products.  In  infectious  diarrhea 
the  bacteria  either  directly  attack  and  live  upon  the  tissues  of  the 
host,  or  their  products  are  more  markedly  injurious;  in  either  case 
serious  lesions  are  produced  in  the  intestine.  Nevertheless  the 
distinction  between  the  two  conditions  is  not  very  sharply  drawn  on 
the  etiological  side,  and  must  be  regarded  as  somewhat  of  a  con- 
cession to  the  demands  of  the  clinical  picture. 

ETIOLOGY. — In  almost  no  aspect  of  scientific  medicine  is  our 
knowledge  so  deficient  as  in  intestinal  bacteriology.  The  subject 
is  so  enormously  complicated,  and  its  investigation  is  attended  by 
such  excessive  technical  difficulties,  that  at  the  present  day  we  can- 
not say  that  more  than  a  beginning  has  been  made  in  its  study. 
The  greatest  difficulty  is  that  probably  no  real  light  on  the  subject 
is  thrown  by  the  examination  of  the  fecal  bacteria.  There  is  a  certain 
amount  of  evidence  which  associates  certain  varieties  of  bacteria, 
such  as  the  butyric  acid  bacillus,  the  bacillus  putrificus,  the  bacillus 
perfringens  (Tissier),  and  the  colon  bacillus,  with  fermental  diarrhea. 

The  studies  of  Kendall  on  bacterial  metabolism  are  interesting 
and  suggestive  in  connection  with  this  subject.  He  divides  bacteria 
into  three  groups,  as  follows: — i,  obligate  carbohydrate  fermenters, 
which  must  have  a  sufficiency  of  carbohydrate  in  order  to  develop; 
2,  obligate  protein  splitters  (putrefactive  group),  which  must  have 
protein;  (3),  facultative  organisms,  which  can  live  on  either  carbo- 
hydrate or  protein,  but  which  normally  ferment  carbohydrate.  The 
products  of  excessive  carbohydrate  fermentation  are  only  locally 
irritating,  although  disturbance  of  metabolism,  toxic  symptoms,  and 
acidosis  may  be  produced  as  the  result  of  the  loss  of  water,  salts, 
and  food  elements  caused  by  the  diarrhea.  The  products  of  exces- 
sive protein  putrefaction  may  be  actually  toxic,  and  may  produce 


444  Diseases  of  the  Gastro-Enteric  Tract 

symptoms  after  absorption.  The  normal  condition  is  one  of  fairly 
even  balance,  carbohydrate  fermentation  predominating;  the  facul- 
tative group  subsist  on  carbohydrate.  Carbohydrate  fermentation 
may  be  in  excess,  and  produce  the  symptoms.  On  the  other  hand 
protein  putrefaction  may  be  in  excess,  either  through  the  introduc- 
tion from  without  of  obligate  putrefiers,  or  from  the  facultative 
organisms  attacking  the  protein. 

The  actual  exciting  causes  which  lead  to  excessive  abnormal  bac- 
terial fermentation  in  the  intestine,  are  not  clearly  understood. 
Probably  a  number  of  factors  are  concerned,  some  operating  in  one 
case,  others  in  another. 

The  disease  is  most  common  in  the  first  two  years  of  life.  It  is 
extremely  rare  in  babies  whose  food  is  human  milk.  There  is  no 
disease  in  which  seasonal  influences  play  so  prominent  a  part,  the 
disease  being  comparatively  rarely  seen  in  the  winter  and  spring, 
but  being  very  common  in  the  summer  and  early  autumn.  Its 
great  prevalence  lasts  until  November. 

The  prevalence  of  the  disease  in  artificially-fed  infants,  and  in 
the  hot  months  of  the  year,  has  led  to  the  conclusion  that  the  exciting 
cause  is  usually  contaminated  milk.  In  hot  weather  there  is  in- 
creased opportunity  for  the  development  in  milk  of  abnormal  organ- 
isms, particularly  of  types  belonging  to  the  putrefactive  group.  In 
spite  of  the  attractiveness  of  the  theory,  bacteriological  examinations 
of  milk  supplies  have  failed  to  afford  much  evidence  of  its  truth. 
There  is  no  doubt  that  the  introduction  of  abnormal  organisms  in 
milk  is  one  of  the  exciting  causes  of  indigestion  with  fermentation, 
but  it  probably  does  not  play  a  part  which  is  in  any  way  exclusive. 

Indigestion  with  fermentation  can  occur  in  infants  who  are  fed 
from  a  milk  supply  known  to  be  of  the  best,  and  even  in  infants 
fed  on  milk  which  has  been  pasteurized  or  sterilized.  In  such  cases 
we  must  look  to  some  disturbance  of  the  digestive  function  as  the 
precipitating  cause  of  the  disease.  Even  with  the  little  which  we 
know  about  intestinal  bacteriology,  it  is  easy  to  conceive  how  a  sud- 
den disturbance  of  the  digestive  function  might  alter  the  quantity 
and  quality  of  the  fermentable  food  residue  in  the  intestine,  in  such 
a  way  as  to  markedly  disturb  the  bacterial  balance  and  permit  exces- 
sive abnormal  fermentation.  Nevertheless,  the  acute  and  often 
severe  disturbances  which  characterize  indigestion  with  fermenta- 
tion are  rarely  associated  with  overfeeding  with  a  particular  food 
element.  Overfeeding  with  carbohydrate  will  produce  signs  of  ex- 
cessive acid  fermentation,  but  usually  not  the  severe  acute  disturb- 
ance which  is  often  seen  in  summer  when  there  has  been  no  dietary 
indiscretion.  Relative  overfeeding  with  the  different  food  elements 
is  common  at  all  times  of  year,  and  cannot  account  for  the  preva- 
lence of  indigestion  with  fermentation  in  hot  weather. 


Indigestion  with  Fermentation  445 

In  all  forms  of  indigestion  in  which  excess  of  food  plays  a  part, 
the  excess  is  relative.  Sometimes  the  precipitating  factor  is  actual 
overfeeding,  while  at  other  times  it  is  a  sudden  lowering  of  the  diges- 
tive power.  We  have  seen  already  that  the  latter  factor  is  par- 
ticularly likely  to  produce  acute  disturbance,  and  that  the  most 
common  cause  of  sudden  lowering  of  the  digestive  power  is  heat. 
We  know  nothing  about  what  actually  takes  place  in  the  intestine 
under  such  circumstances,  nor  whether  the  changes  produced  in  the 
intestinal  contents  differ  from  those  produced  when  the  cause  is 
actual  excess  of  food.  It  is  possible,  if  not  probable,  that  the  changes 
produced  when  the  digestive  power  is  suddenly  lowered  are  different, 
and  are  of  such  a  character  as  particularly  to  disturb  the  bacterial 
balance,  and  to  cause  excessive  fermentation.  Such  a  theory  would 
account  for  the  prevalence  of  indigestion  with  fermentation  in  sum- 
mer, and  would  make  it  the  same  in  etiology  as  many  cases  of  indi- 
gestion from  excess  of  food  as  a  whole,  with  the  additional  bacterial 
element. 

PATHOLOGICAL  ANATOMY.— In  indigestion  with  fermenta- 
tion, the  anatomical  changes  seen  in  the  intestine  are  comparatively 
shght.  In  the  majority  of  cases  coming  to  autopsy,  all  that  is  seen 
is  a  congestion  of  the  blood-vessels  of  the  mucous  membrane.  In 
some  cases  a  mild  catarrhal  inflammation  is  seen,  with  increased 
formation  of  mucus,  and  a  little  cellular  exudation.  One  prominent 
feature  of  the  disease  is  that  there  is  no  relation  between  the  severity 
of  the  anatomical  changes  and  the  severity  of  the  clinical  symptoms; 
In  the  most  severe  cases,  with  pronounced  toxic  symptoms,  no  ana- 
tomical changes  may  be  found  in  the  intestine,  while  some  catarrhal 
inflammation  may  be  present  in  cases  which  cHnically  are  of  the 
mildest  character. 

In  very  severe  cases  the  tissues  of  the  body  in  general  are  drained 
of  water.  There  may  also  be  degenerative  changes  in  the  parenchy- 
matous organs,  particularly  in  the  liver  and  kidneys.  Necrosis  is 
the  lesion  I  have  seen  most  often  in  the  liver. 

Otitis  media,  bronchitis,  bronchopneumonia,  and  pyelitis  are  often 
seen  as  secondary  complications  in  severe  cases. 

SYMPTOMS.— This  disease  is  usually  acute.  The  constant 
symptoms  are  diarrhea  and  loss  of  weight.  Other  symptoms  often, 
seen  are  fever,  vomiting,  and  symptoms  of  toxemia  aft'ecting  the 
nervous  system.  The  severity  of  the  clinical  manifestations  is  very 
variable.  Even  in  mild  cases,  however,  the  diarrhea  is  usually  more 
severe  than  in  indigestion  from  an  excess  of  food. 

The  Mild  Type. — In  the  mild  type  of  the  disease,  the  diarrhea  is 
the  principal  symptom.  The  infant  begins  suddenly  to  have  frequent 
loose  movements.     The  number  of  movements  in  twenty-four  hours 


446  Diseases  of  the  Gastro-Enteric  Tract 

may  vary  from  eight  to  twenty  or  thirty.  The  appearance  of  the 
stools  varies  according  to  whether  the  process  is  one  of  carbohy- 
drate fermentation,  or  of  protein  putrefaction.  Usually  in  the  mild 
type,  the  symptoms  are  due  to  an  excess  of  the  acid  forming  organisms, 
and  consequently  the  stools  are  green  in  color,  acid  in  reaction  and 
odor,  and  irritating  to  the  buttocks.  They  are  usually  watery  in 
consistency,  are  sometimes  frothy  in  appearance,  and  often  contain 
small,  soft,  fat  curds,  or  a  considerable  amount  of  mucus. 

Vomiting  is  uncommon  in  this  comparatively  mild  type.  Loss  of 
appetite  is  usually  present.  There  may  be  a  moderate  febrile  reac- 
tion in  the  beginning  of  the  attack,  but  the  temperature  rarely  goes 
above  ioi°  F.,  and  the  fever  rarely  persists  for  more  than  one  or 
two  days.  Toxic  symptoms  are  absent.  Loss  of  weight  is  always 
present,  varying  with  the  severity  of  the  diarrhea;  it  may  be  marked, 
even  in  comparatively  mild  cases. 

The  Severe  Type. — In  the  severe  type  the  severity  of  the  diar- 
rhea may  not  be  any  greater  than  in  the  mild  type.  In  some  cases, 
however,  the  diarrhea  is  much  more  severe,  the  bowels  moving  so 
frequently  that  the  number  of  movements  in  twenty-four  hours  is 
not  counted.  In  these  cases,  whenever  the  infant  is  changed,  a 
watery  stain  is  found  on  the  napkin.  The  stools  are  usually  very 
watery,  though  occasionally  they  may  have  a  more  fecal  consis- 
tency. They  are  often  frothy.  In  color  they  may  be  green,  brown, 
or  yellowish-brown.  The  color  of  the  stools  is  not  necessarily  an 
indication  of  whether  the  organisms  producing  the  disease  belong  to 
the  carbohydrate-splitting  group,  or  to  the  protein-sphtting,  putre- 
factive group.  It  is  probable  that  severe  cases  can  be  produced  by 
both  types  of  organisms.  Brown,  dark-brown,  or  yellowish-brown 
stools  suggest  proteolytic  bacterial  activity,  but  it  is  probable  that 
green  stools  may  also  occur  in  putrefactive  conditions.  If  the  stools 
are  acid  in  reaction  and  odor,  irritate  the  buttocks,  and  contain 
mucus,  the  evidence  points  toward  abnormal  activity  of  the  organisms 
which  ferment  carbohydrate.  If  the  stools  are  alkaline,  with  a  foul, 
putrid  odor,  and  contain  neither  curds  nor  mucus,  the  evidence 
points  to  abnormal  activity  of  the  proteolytic  group.  The  value  of 
this  evidence  has  not,  however,  been  conclusively  proved  by  bac- 
teriological investigation. 

In  the  severe  type  vomiting  may  be  present  or  absent,  moderate 
or  severe.  It  is  in  no  way  characteristic.  Fever  is  usually  present 
at  the  beginning  of  the  attack.  The  elevation  of  temperature  may 
be  moderate,  or,  in  severe  cases,  it  may  reach  104°  F.  in  the  first 
twenty-four  hours.  Fever  rarely  persists  for  more  than  a  few  days, 
and  in  many  severe  cases,  as  the  disease  progresses,  and  before  the 
other  symptoms  have  improved,  the  temperature  may  be  persistently 


Indigestion  with  Fermentation  447 

subnormal.  In  some  cases  a  subnormal  temperature  is  the  rule  after 
the  first  twenty-four  hours.  In  other  cases  moderate  fever  may 
persist  for  a  week  or  more.  Loss  of  weight  is  always  rapid  and  severe. 
The  urine  is  usually  diminished  in  quantity.  A  leucocytosis,  usually 
not  over  20,000,  is  usually  present.  It  is  not  characteristic,  as  it 
may  be  either  higher,  or  absent  entirely. 

Toxic  symptoms  are  frequently  seen  in  severe  cases  of  indigestion 
with  fermentation.  These  symptoms  may  be  produced  either  by  the 
absorption  of  the  products  of  protein  putrefaction  or  by  the  chemical 
disturbances  of  metabolism  caused  by  the  loss  of  water,  salts,  and 
food  elements.  This  disturbance  is  probably  most  often  a  relative 
acidosis. 

The  most  common  severe  symptom  in  indigestion  with  fermenta- 
tion is  marked  prostration.  The  infant  may  appear  excessively 
feeble,  with  cold  extremities.  Collapse  may  occur  at  any  time. 
These  patients  have  a  peculiar  hollow,  sunken  appearance  of  the 
eyes,  a  sort  of  "abdominal  expression"  resembling  that  seen  in  gen- 
eral peritonitis.  They  take  Kttle  notice  of  their  surroundings,  and 
may  be  actually  comatose.  Their  hmbs  feel  markedly  relaxed.  In 
this  stage  the  temperature  is  very  apt  to  be  subnormal. 

In  other  cases  there  are  signs  of  toxic  irritation  of  the  nervous 
system.  Marked  restlessness  is  common,  and  muscular  twitchings 
are  often  seen.  Even  convulsions  may  occur.  The  nervous  symp- 
toms may  be  those  of  meningeal  irritation,  with  rigidity  of  the  neck, 
retraction  of  the  head,  inequality  of  the  pupils,  exaggerated  knee- 
jerks,  Kernig's  sign,  Brudzinski's  neck  sign,  and  so  forth.  Any 
symptom  characteristic  of  meningitis  may  be  present.  In  some 
cases  there  may  be  excessive  vomiting.  The  temperature  is  variable 
in  this  stage;  it  may  be  subnormal,  moderate,  or,  in  some  cases,  there 
may  be  hyperpyrexia. 

In  severe  cases  death  may  occur  at  any  period  of  the  disease, 
usually  with  all  the  signs  of  collapse  and  circulatory  failure.  In 
cases  which  recover,  relapses  are  fairly  common  in  hot  weather,  even 
in  infants  who  are  carefully  fed.  Infants  who  have  survived  fre- 
quent acute  a'ttacks  of  indigestion  with  fermentation  present  toward 
the  end  of  the  summer  a  fairly  characteristic  picture.  They  are 
greatly  emaciated,  presenting  the  picture  of  infantile  atrophy.  Their 
skin  feels  dry  and  wrinkled.  They  have  a  subnormal  temperature— - 
and  cold  extremities.  The  buttocks  are  irritated;  their  eyes  are 
hollow  and  sunken.  Such  cases  are  liable  to  collapse  and  death 
at  any  time. 

DIAGNOSIS — There  are  two  conditions  characterized  clinically 
by  acute  diarrhea,  from  which  indigestion  with  fermentation  must 
be  distinguished.     These  are  indigestion  from  an  excess  of  food  as 


448  Diseases  of  the  Gastro-Enteric  Tract 

a  whole,  and  infectious  diarrhea.  It  is  known  that  a  certain  amount 
of  bacterial  fermentation  occurs  in  simple  indigestion,  and  the  dis- 
tinction is  mainly  one  of  degree.  In  simple  indigestion  the  diarrhea 
is  not  severe,  fever  is  usually  absent,  toxic  symptoms  are  absent, 
loss  of  weight  is  less  marked,  and  the  stools  are  undigested.  The 
movements  in  simple  indigestion  may  be  somewhat  green  in  color, 
but  they  are  not  watery,  frothy,  or  foul,  and  contain  curds  or  un- 
digested masses. 

In  infectious  diarrhea  there  is  fever  and  toxic  symptoms,  but  the 
character  of  the  stools  is  wholly  different.  They  consist  mainly 
of  mucus,  or  at  least  contain  an  excessive  amount  of  mucus,  and 
often  contain  specks  or  streaks  of  blood,  and  sometimes  pus.  They 
do  not  show  much  evidence  of  fermentation.  The  fever  in  infectious 
diarrhea  is  usually  much  more  persistent,  though  the  initial  tem- 
perature is  often  not  so  high. 

The  forms  of  indigestion  caused  by  relative  overfeeding  with  the 
various  individual  food  elements  may  at  times  have  diarrhea  as  a 
symptom,  but  those  forms  are  essentially  chronic,  and  the  diarrhea 
only  appears  as  a  temporary  phenomenon  in  a  case  which  has  been 
exhibiting  chronic  symptoms.  Carbohydrate  indigestion  is  the  form 
showing  the  greatest  tendency  to  diarrhea,  but  in  cases  giving  a  defi- 
nite history  of  carbohydrate  overfeeding,  the  diarrhea  is  not  so  severe 
as  in  the  primary  type  classified  as  indigestion  with  fermentation. 
In  any  case  occurring  in  summer,  with  the  sudden  appearance  of 
severe  diarrhea,  and  watery,  green,  or  foul  stools,  acute  indigestion 
with  fermentation  is  the  most  probable  diagnosis. 

No  satisfactory  method  has  been  worked  out  by  which  the-  diag- 
nosis of  indigestion  with  fermentation  can  be  confirmed  by  a  bac- 
teriological examination  of  the  stools.  With  the  methods  of  exami- 
nation at  present  available,  the  stools  show  no  constant  or  char- 
acteristic bacteriological  findings.  Cultural  methods  are  only  of 
value  in  excluding  infectious  diarrhea. 

PROGNOSIS. — The  frequency  of  occurrence,  and  the  severity  of 
indigestion  with  fermentation  is  variable  in  different*  parts  of  the 
country.  In  any  one  locality  the  frequency  and  severity  of  the 
disease  vary  greatly  in  different  summers.  I  have  known  summers 
when  I  have  seen  more  deaths  from  indigestion  with  fermentation 
than  from  infectious  diarrhea. 

The  prognosis  depends  greatly  on  the  treatment.  Mild  cases  may 
easily  be  converted  into  severe  ones  by  improper  treatment,  and 
severe  ones  may  be  made  fatal.  With  proper  treatment  the  prog- 
nosis of  mild  cases  due  to  excessive  fermentation  of  carbohydrate 
is  very  good.  In  severe  cases,  with  toxic  symptoms,  the  prognosis 
is  always  grave.     It  is  especially  serious  in  the  type  characterized 


Indigestion  with  Fermentation  449 

by  dark  brown  stools  with  a  foul  or  musty  odor.  When  severe  cases 
survive  the  first  three  or  four  days  they  usually  recover  from  that 
particular  attack.  Recurrence  often  occurs  in  hot  weather,  unless 
the  greatest  care  be  taken;  unless  faulty  hygienic  surroundings  can 
be  corrected  recurrence  is  almost  certain.  An  infant  may  survive 
several  attacks,  and  finally  succumb  to  an  attack  occurring  in  the 
autumn.  Bad  treatment  greatly  increases  the  gravity  of  the  prog- 
nosis. I  have  seen  a  single  dose  of  paregoric  in  a  comparatively  mild 
case  followed  by  death  from  toxic  symptoms  within  a  few  hours. 

TREATMENT.  Routine.— The  first  step  in  the  treatment  of 
every  case  of  acute  indigestion  with  fermentation  is  to  empty  thor- 
oughly the  intestinal  tract.  Castor  oil  is  the  best  purgative  which 
can  be  used  for  the  purpose.  One  teaspoonful  may  be  given  to 
infants  in  the  first  three  months,  two  teaspoonfuls  from  three  to 
eighteen  months,  and  three  teaspoonfuls  to  older  infants.  Children 
should  take  from  a  dessertspoonful  to  a  tablespoonful,  according  to 
age.  If  the  castor  oil  is  vomited,  calomel  should  be  given,  to  babies 
in  the  first  year  in  doses  of  one-tenth  of  a  grain  every  half  hour  for 
ten  doses,  and  in  the  second  year  in  doses  of  one-fourth  of  a  grain 
every  half  hour  for  six  doses,  and  to  older  children  in  doses  of  one- 
fourth  of  a  grain  every  half  hour  for  eight  doses.  Two  hours  after 
the  last  dose,  two  or  three  teaspoonfuls  of  milk  of  magnesia  should 
be  given. 

From  the  time  of  giving  the  castor  oil,  or  of  beginning  the  calomel, 
the  giving  of  all  food  should  be  stopped  for  from  twelve  to  twenty- 
four  hours.  If  food  be  given,  the  emptying  of  the  intestine  will  be 
useless,  and  the  castor  oil  or  calomel  might  just  as  well  not  have 
been  given.  Many  mothers  have  learned  that  castor  oil  is  good 
routine  treatment  for  acute  diarrhea,  but  have  not  learned  that  to 
be  effective  it  must  be  followed  by  a  period  of  withholding  food. 
During  this  period  water  must  be  given  freely,  in  a  quantity  at  least 
equal  to  the  quantity  of  fluid  which  the  baby  would  take  if  it  were 
receiving  its  ordinary  food.  The  water  may  be  given  in  the  bottle 
or  from  a  cup,  as  preferred  by  the  child,  and  may  be  either  warm  or 
cool,  according  to  the  taste  of  the  child.  If  sufficient  water  be  not 
taken,  it  must  be  given  with  a  spoon,  and  if  there  is  still  difficulty 
in  getting  in  the  desired  quantity,  it  must  be  given  through  a  tube. 
It  may  be  sweetened  with  saccharin,  if  taken  better  that  way. 

The  length  of  the  period  of  withholding  food  should  not  be  more 
than  twenty-four  hours.  When  lactic  acid  milk  is  available,  it  need 
not  be  more  than  twelve  hours.  If  for  any  reason  lactic  acid  milk 
cannot  be  used  in  the  treatment  of  the  case  it  is  usually  better  not 
to  give  milk  in  any  form  for  a  second  twenty-four  hours.  During 
this  period  barley  water  may  be  given. 
29 


450  Diseases  of  the  Gastro-Enteric  Tract 

After  twelve  hours,  usually,  feeding  should  be  begun  with  lactic 
acid  milk  made,  if  possible,  from  a  culture  of  the  lactic  acid  bacillus 
which  has  known  anti-putrefactive  properties.  The  lactic  acid  milk 
should  be  made  from  fat-free,  or  skimmed  milk,  and  should  not  be 
heated  after  the  process  of  "ripening,"  in  order  that  living  bacilH 
may  be  given.  Lactic  acid  milk  may  be  tried  first  undiluted.  If 
it  causes  vomiting,  or  if  curds  appear  in  the  stools,  it  may  be  diluted. 

Basis  for  Treatment  with  Lactic  Acid  Milk. — I  beHeve  lactic 
acid  milk  to  be  by  far  the  best  routine  treatment  for  cases  of  fer- 
mental  diarrhea.  The  object  to  be  attained  by  treatment  is  the 
inhibition  of  abnormal  bacterial  activity,  and  the  restoration  of 
normal  bacterial  conditions  in  the  intestinal  canal.  The  abnormal 
bacteria  cannot  be  completely  removed  by  purgatives,  and  will  con- 
tinue to  ferment  all  food  given,  unless  combatted  in  some  other  way. 
Intestinal  antiseptics  are  absolutely  useless,  because  they  cannot  be 
given  in  doses  large  enough  to  kill  the  bacteria  without  injuring  the 
patient.  The  offending  microorganisms  cannot  be  removed  by 
irrigations  of  the  colon,  because  they  are  situated  mainly  in  the 
small  intestine,  and  the  fluid  in  a  colon  irrigation  does  not  go  above 
the  iliocecal  valve. 

There  are  two  ways  in  which  the  abnormal  bacterial  activity 
which  is  causing  the  disease  can  be  checked.  One  is  by  the  intro- 
duction into  the  intestinal  canal  of  microorganisms  antagonistic  to 
the  offending  micro5rganisms.  The  other  is  by  altering  the  chem- 
ical composition  of  the  food  in  such  a  way  as  to  provide  a  culture 
medium  unsuitable  for  the  abnormal  fermentation  which  is  present. 

Many  years  ago  Tissier  showed  at  the  Pasteur  Institute  at  Paris, 
that  the  bacillus  bifidus,  an  organism  normally  present  in  the  intes- 
tine, has  an  inhibitory  action  on  the  bacillus  perfringens,  which  he 
found  in  certain  abnormal  conditions.  The  B.  bifidus,  however, 
being  an  anaerobe,  was  not  suited  to  cultivation  for  therapeutic 
purposes,  and  Tissier  advocated  the  use  of  the  lactic  acid  bacillus 
in  fermental  diarrhea.  Since  then,  considerable  evidence  of  the  value 
of  the  lactic  acid  bacillus  in  inhibiting  the  development  of  various 
microorganisms  has  been  brought  forward.  Metchnikoff  demon- 
strated its  value  in  inhibiting  the  growth  of  many  of  the  saprophytes 
of  putrefaction.  Not  only  is  it  effective  against  the  B.  perfringens, 
and  other  bacilH  of  the  gas-forming  group,  but  there  is  evidence 
that  it  is  effective  against  many  proteolytic  types,  and  against  the 
B.  acidophilus. 

If  it  were  possible  in  fermental  diarrhea  to  know  just  what  type 
of  microorganism  was  causing  the  disturbance  we  would  know  just 
when  to  use  the  lactic  acid  bacillus.  This  is  impossible  with  our 
present  diagnostic  methods.  We  know,  however,  that  protein  putre- 
faction is  one  dangerous  form  of  bacterial  activity.     We  cannot  be 


Indigestion  with  Fermentation  451 

certain  in  any  case  whether  the  disturbance  is  caused  by  proteo- 
lytic or  by  carbohydrate-sphtting  organisms;  if  by  the  latter, 
carbohydrate  is  contraindicated,  and  protein  should  be  given.  It 
would  not  be  safe,  however,  to  give  protein,  unless  we  could  guard 
against  a  possible  increase  in  proteolytic  bacterial  activity.  By 
giving  a  food  containing  great  numbers  of  living  lactic  acid  bacilli, 
we  can  prevent  excessive  proteolytic  activity  through  the  antago- 
nistic action  of  that  organism.  Lactic  acid  milk  not  only  contains 
great  numbers  of  lactic  acid  bacilli,  but  is  relatively  low  in  carbo- 
hydrate and  high  in  protein.  It  is  therefore  an  ideal  food  for  the 
treatment  of  a  condition  in  which  we  can  never  be  sure  of  the  exact 
character  of  the  abnormal  bacterial  processes  in  the  intestine.  If 
the  case  is  one  of  protein  putrefaction,  the  lactic  acid  bacilli  will 
antagonize  the  proteolytic  organisms,  and  bring  about  a  normal 
bacterial  balance,  while  the  carbohydrate  in  the  food  and  the  protein, 
protected  from  attack,  will  nourish  the  patient.  If  the  case  is  one 
of  excessive  carbohydrate  fermentation,  we  are  using  a  food  rela- 
tively high  in  protein  and  low  in  carbohydrate,  which  is  just  what 
is  needed.  The  only  reason  for  using  a  lactic  acid  milk  which  does 
not  contain  fat  is  that  in  the  presence  of  lactic  acid  the  fat  globules 
tend  to  run  together  in  the  form  of  butter,  which  is  difficult  of 
digestion. 

If  the  best  results  are  to  be  obtained,  it  is  essential  that  a  culture 
of  the  lactic  acid  bacillus  be  used  in  ripening  the  milk  which  is  of 
known  antiputrefactive  value.  There  are  many  strains  of  the  lactic 
acid  bacillus,  and  all  are  not  of  equal  value  for  therapeutic  pur- 
poses. There  is  evidence  that  the  so-called  Bulgarian  bacillus  is  a 
valuable  strain,  but  other  strains  have  been  isolated  which  have  given 
evidence  of  equally  strong  antagonistic  action  against  various  organ- 
isms. It  is  best  if  possible,  always  to  use  a  strain  of  which  the  anti- 
putrefactive action  has  been  tested. 

The  lactic  acid  bacilli  should  be  given  alive,  in  some  fluid  medium. 
They  are,  in  my  experience,  not  as  effective  when  some  dry  prepara- 
tion in  tablet  form  is  used,  as  when  bouillon  cultures  are  used.  The 
bacilli  may  be  given  directly  to  the  patient  in  the  form  of  bouillon 
cultures,  but  in  my  experience  it  is  much  better  to  use  either  butter- 
milk, or  ripened  modified  milk.  The  latter  is  really  the  most  rational 
method,  as  it  allows  the  chemical  composition  of  the  food  to  be 
fitted  to  the  digestive  requirements  of  the  individual  infant.  The 
advantage  of  giving  lactic  acid  bacilli  in  the  food  rather  than  in  the 
form  of  bouillon  cultures  is,  first,  that  in  the  former  way  greater 
numbers  of  the  bacilli  are  administered;  second,  that  more  lactic 
acid,  which  itself  has  an  antagonistic  action  against  certain  forms  of 
abnormal  bacterial  activity,  is  present;  third,  that  the  protein  is 
already  precipitated  in  a  very  finely  divided  form,  being  consequently 


452  Diseases  of  the  Gastro-Exteric  Tract 

easier  of  digestion;  and  fourth,  that  the  ripening  process  lowers  the 
percentage  of  carbohydrate  by  converting  some  of  the  sugar  into 
lactic  acid.  It  is  obvious  why  ripened  milk  given  for  the  treatment 
of  fermental  diarrhea  must  not  be  boiled  or  pasteurized  after  the 
addition  of  the  culture. 

Alterxatr^e  Treatmext. — In  case  treatment  with  lactic  acid 
milk  is  either  not  available,  or  fails  to  be  followed  by  a  favorable 
result,  the  only  way  in  which  abnormal  bacterial  fermentation  can 
be  inhibited  is  by  making  some  change  in  the  character  of  the  food. 
In  selecting  a  food  for  these  cases  the  physician  must  form  an  idea 
from  the  clinical  symptoms  as  to  whether  the  abnormal  fermentation 
involves  the  carbohydrate-sphtting  group  of  organisms,  or  the  pro- 
teolytic. Unfortunately  such  a  conclusion  can  never  be  positive, 
until  some  method  of  accurate  bacteriological  diagnosis  is  discovered. 
It  is,  however,  the  only  available  basis  of  treatment,  as  the  changes 
which  are  made  in  the  composition  of  the  food  depend  on  which  form 
of  fermentation  is  present.  In  this  disease  therapeutic  progress  has 
outstripped  progress  in  diagnosis. 

When  the  cUnical  evidence,  green,  acid,  irritating  stools,  and  so 
forth,  points  toward  excessive  abnormal  carbohydrate  fermentation, 
the  milk  should  be  modified  as  for  the  treatment  of  carbohydrate 
indigestion. .  The  food  should  be  low  in  carbohydrate,  not  more 
than  3%  or  4%,  and  maltose  is  usually  preferable  to  lactose  as  being 
less  fermentable,  unless  the  baby  has  been  previously  fed  on  a  food 
containing  maltose.  The  percentage  of  fat  should  also  be  low,  1% 
or  2%,  because  excessive  carbohydrate  fermentation  often  leads  to 
great  difficulty  in  digesting  fat,  and  to  the  disturbance  of  metabolism 
caused  by  fat  indigestion.  The  percentage  of  protein  should  be 
high,  2%  to  3%. 

When  the  clinical  evidence,  browm,  musty  or  foul  stools,  and  so 
forth,  points  toward  excessive  protein  putrefaction,  the  percentage 
of  protein  should  be  low,  at  first  not  more  than  0.5%.  The  per- 
centage of  carbohydrate  should  be  high,  6%  or  7%,  and  the  extra 
sugar  added  should  be  lactose,  not  maltose.  The  fat  may  be  from 
1%  to  2%,  In  very  severe  cases,  obviously  due  to  proteolytic  organ- 
isms, when  lactic  acid  milk  is  not  available,  or  has  failed,  all  protein 
should  be  excluded  for  twenty-four  hours,  and  the  infant  may  be 
fed  during  this  period  on  a  6%  lactose  solution. 

Theoretically,  if  the  organisms  are  of  the  butyric  acid  forming 
type,  the  fat  in  the  food  should  be  very  low.  Such  a  condition  is 
difficult  to  recognize  chnically.  If,  however,  the  stools  should  have 
a  distinct  butyric  acid  odor,  fat  should  be  entirely  excluded  from 
the  food,  and  the  carbohydrate  should  be  low  in  percentage. 

CoNTRAiNDiCATioxs  IN  TREATMENT. — In  the  feeding  of  cases  of 


Indigestion  with  Fermentation  453 

acute  indigestion  with  fermentation,  certain  foods  should  not  be 
used.  Prominent  among  the  contraindicated  foods  are  whey,  whey 
mixtures,  albumen  water,  and  beef  juice.  Whey  and  whey  mixtures 
are  high  in  lactose  content,  and  are  therefore  bad  if  the  abnormal 
fermentation  should  involve  the  carbohydrate.  In  conditions  of 
protein  putrefaction,  whey,  albumen  water,  and  beef  juice  all  seem 
to  increase  markedly  the  severity  of  the  symptoms.  This  is  very 
probably  because  the  soluble  albuminous  protein  contained  in  these 
foods  is  a  more  favorable  culture  medium  for  proteolytic  organisms 
than  is  casein.  Another  reason  for  avoiding  albumen  water  and 
beef  juice  is  that  there  is  some  evidence  that  in  acute  diarrheal  con- 
ditions the  foreign  egg  and  beef  protein  may  pass  unchanged  through 
the  intestinal  wall,  and  may  sensitize  the  baby. 

The  opiates  and  astringents  are  positively  contraindicated  at  the 
onset  of  fermental  diarrhea.  The  checking  of  the  diarrhea  at  this 
time  by  any  such  method  necessarily  leads  to  accumulation  of  fer- 
mentation products,  and  may  greatly  increase  the  toxemia.  The  use 
of  opium  will  be  spoken  of  in  the  treatment  of  certain  severe  types. 

Treatment  of  Resistant  Cases. — ^When  treatment  with  lactic 
acid  milk  fails  to  bring  about  an  improvement  in  the  symptoms  of 
fermentation,  the  failure  is  probably  due  to  one  of  three  causes. 
I.  The  lactic  acid  milk  may  cause  protein  indigestion  manifesting 
itself  in  vomiting  or  curdy  stools.  2.  The  carbohydrate  in  the  lactic 
acid  milk  may  not  be  sufficiently  low  to  inhibit  sugar  fermentation. 
3.  The  lactic  acid  bacilli  may  not  have  an  effective  inhibitory  action 
against  the  organisms  causing  the  abnormal  fermentation. 

In  the  first  condition  the  lactic  acid  milk  must  be  given  diluted. 
If  dilution  is  not  successful,  the  milk  must  be  modified  as  described 
above  under  alternative  treatment. 

The  second  condition  is.  suggested  when  the  stools  continue  to  be 
green,  acid,  and  irritating  to  the  buttocks.  In  such  a  case  a  com- 
bination of  lactic  acid  milk  and  precipitated  casein,  such  as  albumin 
milk,  should  be  tried.  This  retains  the  advantages  of  lactic  acid 
milk,  while  permitting  further  reduction  of  the  carbohydrate.  Car- 
bohydrate can  be  almost  entirely  excluded  by  the  use  of  precipi- 
tated casein. 

The  third  condition  is  suggested  by  a  continuance  of  the  original 
symptoms.  Albumin  milk  may  be  tried.  If  it  is  unsuccessful,  the 
case  should  be  treated  with  ordinary  milk  modifications  as  described 
above  under  alternative  treatment. 

Dietetic  After-treatment. — ^When  the  symptoms  due  to  fer- 
mentation have  been  promptly  relieved,  the  baby  will  sometimes  gain 
in  weight  rapidly.  This  is  due  to  increased  water  retention,  the 
drained  tissues  re-supplying  themselves  with  water.     A  very  rapid 


454  Diseases  oe  the  Gastro-Enteric  Tract 

gain  in  weight,  or  gain  in  weight  without  rehef  of  symptoms,  should 
always  be  looked  upon  with  suspicion,  as  it  may  be  due  to  edema. 

Some  infants  will  gain  in  weight  for  a  considerable  time  on  lactic 
acid  milk  or  on  albumin  milk.  In  such  cases  the  diet  should  not  be 
changed  until  the  patients  begin  to  show  a  failure  to  gain  properly 
in  weight.  Many  infants,  in  spite  of  relief  of  symptoms,  will  not 
gain  on  lactic  acid  milk.  Failure  to  gain  on  lactic  acid  milk,  or  on 
albumin  milk,  means  usually  a  deficiency  of  fat,  of  carbohydrate, 
or  of  both  fat  and  carbohydrate.  In  albumin  milk,  the  fat  and 
carbohydrate  can  be  increased  by  the  addition  of  cream  and  sugar 
in  proportions  sufficient  to  gradually  raise  the  percentages  of  those 
food  elements.  When  lactic  acid  milk  has  been  used,  it  is  better 
not  to  add  the  cream  and  sugar  to  the  lactic  acid  milk,  but  to  begin 
with  alternate  feedings  of  lactic  acid  milk  and  some  ordinary  milk 
modification.  Gradually  the  lactic  acid  milk  may  be  dropped,  and 
the  diet  may  be  arranged  in  accordance  with  the  ordinary  principles 
of  feeding.  If  indigestion  develops  the  food  must  be  modified  to  meet 
the  indications.  If  recurrence  of  fermentation  develops,  the  treat- 
ment must  be  begun  over  again,  and  the  return  to  a  normal  diet  must 
be  more  cautious. 

Treatment  oe  Alimentary  Intoxication. — In  cases  showing  the 
symptom-complex  often  described  as  "alimentary  intoxication"  some 
modifications  of  the  routine  treatment  must  be  made.  If  the  infant 
has  been  having  severe  diarrhea  for  a  considerable  time,  with  very 
frequent  watery  stools,  and  a  retracted  abdomen,  the  intestines  are 
already  as  empty  as  they  can  be  made,  and  a  purgative  may  in- 
crease the  loss  of  water  and  salts,  and  possibly  act  as  an  additional 
irritant,  without  any  compensating  benefit  from  the  removal  of  fer- 
menting food  residue.  In  this  condition,  therefore,  the  preliminary 
emptying  of  the  bowel  should  be  omitted.  The  rest  of  the  routine 
treatment  in  feeding  should  be  followed,  but  feeding  with  lactic  acid 
milk  may  be  begun  at  once. 

In  these  toxic  cases  it  must  be  remembered  that  the  symptoms 
may  be  due  to  two  causes,  one  being  the  absorption  of  toxic  products 
from  the  intestine,  the  other  being  the  occurrence  of  a  relative  acidosis 
from  loss  of  alkaline  bases.  (See  diagram,  p.  398.)  We  rely  on  the 
antagonistic  action  of  the  lactic  acid  bacilli  to  relieve  the  first  form 
of  toxemia,  and  its  effect  is  sometimes  very  striking,  especially  in 
cases  caused  by  the  activity  of  the  proteolytic  t3^e  of  organisms. 
In  the  second  form  of  toxemia  the  indications  are  to  check  the  excess- 
ive loss  of  salts  in  the  stools,  and  to  neutralize  the  relative  acidity 
of  the  blood. 

In  either  case  the  severity  of  the  disease  is  much  increased  by  the 
loss  of  water  from  the  tissues.     In  all  severe  cases,  with  toxic  symp- 


Indigestion  with  Fermentation  455 

toms  or  collapse,  one  of  the  chief  therapeutic  indications  is  to  supply 
the  tissues  with  as  much  fkiid  as  possible.  The  giving  of  fluid  by- 
mouth  is  often  much  interfered  with  by  vomiting  or  by  a  continuance 
of  the  diarrhea,  and  fluid  must  therefore  be  suppHed  in  other  ways. 
It  may  be  given  by  rectum,  continuously  by  the  drop  method.  (See 
Division  II,  section  on  General  Therapeutics.)  The  fluid  is  often  not 
well  retained  and  absorbed  when  given  by  this  method.  Fluid  may 
be  given  subcutaneously  when  not  retained  by  rectum.  At  times 
however,  in  very  sick  infants,  its  absorption  is  very  slow.  In  the 
most  severe  cases  it  is  best  given  intravenously.  Not  more  than  four 
ounces  of  fluid  should  be  given  intravenously  at  any  one  adminis- 
tration to  a  baby  under  one  year. 

In  cases  in  which  the  toxic  symptoms  are  not  relieved  soon  after 
feeding  with  lactic  acid  milk  is  begun,  or  in  which  the  symptom-com- 
plex is  strongly  suggestive  of  a  relative  acidosis,  an  alkali  is  indicated. 
The  symptoms  suggesting  an  acidosis  are  severe  watery  diarrhea  of 
the  acid-carbohydrate  type,  concentrated  urine  full  of  ammonia,  and 
any  dyspnoea.  Sodium  bicarbonate  may  be  given  by  mouth  in  doses 
of  40  to  60  grains  (3  or  4  grams),  half  an  hour  before  each  feeding. 
When  the  sodium  bicarbonate  produces  digestive  disturbance,  is  not 
retained,  or  when,  on  account  of  the  severity  of  the  case,  sure  and 
quick  action  is  desired,  sodium  bicarbonate  should  be  given  intra- 
venously, in  doses  of  5  or  6  grams  (60  to  90  grains),  diluted  with 
4  ounces  of  water.  The  injections  should  be  repeated,  as  indicated 
by  the  reaction  to  the  treatment,  and  by  the  symptomjS.  I  have 
entirely  discarded  the  subcutaneous  method  of  giving  bicarbonate 
of  soda.  It  is  likely  to  produce  necrosis  of  the  tissues,  and  in  infants, 
the  use  of  the  longitudinal  sinus  has  made  the  technique  of  intra- 
venous injections  so  extremely  easy,  that  I  have  adopted  the  intra- 
venous route  whenever  I  wish  to  give  fluid  or  medication  quickly. 
For  a  description  of  the  technique,  the  reader  is  referred  to  Division 
II,  p.  166. 

When  the  diarrhea  does  not  quickly  respond  to  dietetic  treatment, 
opium  is  the  only  drug  which  will  check  the  excessive  loss  of  water 
and  salts.  It  has  always  been  taught  that  opium  is  very  dangerous 
in  fermental  diarrhea.  If  the  symptoms  are  due  to  the  products  of 
excessive  fermentation  opium  is  dangerous,  as  the  checking  of  peris- 
talsis leads  to  the  increased  retention  and  absorption  of  toxic  pro- 
ducts. In  a  case  of  alimentary  intoxication,  however,  when  the 
bowels  are  empty,  and  when  either  no  food  is  being  given,  or  a  food 
designed  to  antagonize  excessive  fermentation,  the  diarrhea  may  have 
become  habitual,  and  the  loss  of  water  and  salts  may  be  a  more 
serious  menace  than  is  toxic  absorption.  Therefore,  in  a  resistant 
case,  with  continued  severe  diarrhea,  large  watery  stools,  retracted 
abdomen,  and  toxic  symptoms  suggesting  a  relative  acidosis,  opium 


456  Diseases  of  the  Gastro-Enteric  Tract 

may  be  cautiously  tried.  It  is  best  given  in  the  form  of  paregoric, 
in  small  doses  proportioned  to  the  age  of  the  child,  a  few  drops  being 
given  after  each  loose  stool. 

Treatment  of  Special  Symptoms. — The  special  symptoms  re- 
quiring treatment  are  collapse,  toxic  nervous  irritation,  and  excessive 
vomiting. 

When  severe  prostration  and  collapse  occur,  the  best  stimulant 
is  fluid.  In  infants  it  is  best  given  intravenously,  into  the  longi- 
tudinal sinus.  Normal  salt  solution  may  be  used,  or,  if  the  baby 
has  shown  symptoms  suggesting  acidosis,  sodium  bicarbonate  should 
be  given  in  sterile  water,  as  described  for  the  treatment  of  alimen- 
tary intoxication.  I  beHeve  the  collapse  in  many  cases  is  due  to 
failure  to  absorb  enough  energy-producing  food.  Infants  in  collapse 
need  fuel  as  weh  as  water  and  alkah.  I  have  recently  tried  giving 
dextrose  intravenously  in  cases  of  this  kind.  A  quantity  equal  to 
one-sixtieth  of  the  body  weight  of  the  child  of  a  five  per  cent 
dextrose  solution  may  thus  be  given.  In  some  cases  some  of  the 
dextrose  is  excreted  in  the  urine,  but  in  my  experience  part  of  it 
is  always  actually  used  for  energy  production,  and  in  some  cases 
it  has  all  been  used,  none  having  been  excreted  in  the  urine. 
The  use  of  dextrose  may  be  combined  with  sodium  bicarbonate. 
Other  stimulants  which  may  be  used  in  collapse  are  adrenaHn,  in 
doses  of  1  to, 5  minims  intravenously,  strychnine  subcutaneously  in 
doses  of  i/iooo  to  1/200  of  a  grain,  caffeine  sodium-benzoate  or 
salicylate  in  doses  of  1/8  to  1/2  a  grain  subcutaneously,  and  camphor 
in  oil  in  doses  of  i  to  2  grains  intravenously.  Alcohol  is  contra- 
indicated  in  collapse. 

For  the  toxic  nervous  symptoms,  such  as  restlessness  or  signs  of 
meningeal  irritation,  sodium  bromide  is  the  best  drug.  It  is  best 
given  by  mouth  in  doses  of  5  grains,  repeating  in  two  hours  as  often 
as  is  necessary  to  control  the  symptoms.  If  the  fontanelle  is  bulg- 
ing, lumbar  puncture  will  often  give  relief.  Ice  bags  to  the  head 
should  not  be  used  unless  there  is  high  fever,  and  then  cautiously. 

For  excessive  vomiting  the  stomach  should  be  washed  out  with 
a  solution  of  sodium  bicarbonate,  one  teaspoonful  to  a  pint  of  water. 
This  may  be  repeated  daily.  Little  else  can  be  done  for  this  symp- 
tom, as  nutrient  enemata  will  not  be  retained. 


VII.     INFECTIONS 

INFECTIOUS  DIARRHEA 

The  distinction  between  indigestion  with  fermentation  and  infec- 
tious diarrhea  has  been  discussed  under  the  former  disease.  Etio- 
logically  it  is  not  a  very  definite  one,  because  both  diseases  are 
caused  by  bacteria.  In  infectious  diarrhea  the  bacteria,  instead  of 
developing  only  in  the  intestinal  contents,  enter  the  intestinal  wall, 
and  produce  definite  lesions  of  the  tissues.  It  is  probable  also  that 
in  infectious  diarrhea,  as  in  many  other  infections,  bacteria  may 
actually  penetrate  the  blood  vessels  and  enter  the  general  circulation. 
The  chief  distinction,  however,  is  one  of  pathological  anatomy.  It 
has  been  urged  against  the  distinction,  that  in  numerous  cases  in 
which  the  bacillus  dysenteriae  was  actually  demonstrated  as  the 
cause,  there  was  little  anatomical  change  other  than  slight  hyper- 
plasia of  the  lymphatic  tissue  of  the  intestine.  This  condition  fre- 
quently occurred  in  the  report  of  Flexner  and  Holt  on  the  dysentery 
bacillus.  It  is,  however,  only  found  associated  with  dysentery  in- 
fection in  cases  which  succumb  very  rapidly,  before  there  is  time  for 
the  formation  of  pronounced  lesions.  On  the  other  hand,  in  the 
cases  of  the  type  described  as  acute  indigestion  with  fermentation, 
the  disease  can  run  a  long  course  without  the  production  of  demon- 
strable intestinal  lesions. 

Infectious  diarrhea  has  been  frequently  described  under  a  different 
terminology,  being  called  ileo-colitis.  The  basis  for  this  terminology 
is  the  lesions  produced  in  the  intestinal  mucosa.  The  lesions,  how- 
ever, are  not  peculiar  to  infection  with  the  various  forms  of  bacteria 
which  cause  the  clinical  picture  of  infectious  diarrhea,  but  are  seen 
in  other  diseases  of  known  etiology.  An  ileo-colitis  occurs  in  typhoid 
fever,  in  tuberculous  disease  of  the  intestine,  and  sometimes  even 
as  the  result  of  prolonged  irritation  from  some  form  of  indigestion, 
or  from  the  taking  of  some  particularly  irritating  article  of  food. 
The  term  ileo-colitis  therefore  can  only  be  properly  used  to  describe, 
a  certain  form  of  pathological  anatomy  in  the  intestine  which  may 
be  produced  by  various  causes.  For  the  association  of  the  lesions 
of  ileo-colitis  with  a  more  or  less  definite  form  of  infection,  and  a 
very  definite  symptom-complex,  infectious  diarrhea  is  the  best  avail- 
able term. 

ETIOLOGY.  The  Bacteria. — The  microorganisms  which  have 
been  associated  with  infectious  diarrhea  are  the  following: — i,  the 


458  Diseases  of  the  Gastro-Enteric  Tract 

various  strains  of  dysentery  bacillus;  2,  the  gas  bacillus  and  similar 
organisms;  3,  the  streptococcus,  in  various  strains;  4,  the  bacillus 
pyocymieus;  5,  a  few  other  organisms  in  rare  cases. 

There  is  no  doubt  that  the  bacillus  of  dysentery  is  the  most  fre- 
quent cause  of  infectious  diarrhea.  Its  etiological  connection  mth 
the  disease  has  been  proven  beyond  any  question.  The  various 
types  or  strains  of  the  dysentery  bacillus  need  not  be  described  here. 
The  original  Shiga  type,  first  described  by  Shiga  as  causing  the 
ordinary  acute  dysentery  of  Japan,  has  been  found  in  this  country 
in  acute  cases  of  summer  diarrhea.  The  Flexner  t}^e  is  the  com- 
monest in  temperate  chmates.  In  a  report  from  the  Philippines, 
Ohno  has  shown  that  there  are  at  least  fifteen  varieties  of  bacillus 
dysenteriae,  all  closely  related  to  one  another  both  in  morphology 
and  pathogenicity.  The  bacillus  of  dysentery  cannot  usually  be 
demonstrated  in  the  stools  of  normal  infants.  The  few  cases  in 
which  it  has  been  found  in  normal  stools  can  be  explained  on  the 
ground  of  a  recent  previous  attack  of  diarrhea.  The  bacillus  of 
dysentery,  in  one  of  its  strains,  has  been  found  in  as  large  a  propor- 
tion as  90%  of  all  cases  of  infectious  diarrhea,  in  some  investigations. 
The  figures  in  different  reports  depend  greatly  on  the  skill  of  the 
investigators.  The  proportion  of  cases  of  infectious  diarrhea  due  to 
this  organism  probably  varies  in  different  locahties,  and  probably 
also  varies  in  difi'erent  summers  in  the  same  locaUty. 

The  etiologic  role  of  the  gas  bacillus  is  based  on  the  fact  that 
in  certain  epidemics,  or  at  least  in  certain  localities  in  certain  sum- 
mers, large  numbers  of  gas  bacilh  have  been  found  in  the  stools  of 
infants  showing  the  chnical  picture  of  infectious  diarrhea,  while  the 
dysentery  bacillus  was  not  found.  The  etiologic  importance  of  the 
gas  bacillus  is  not,  however,  estabHshed  with  absolute  certainty. 
It  may  frequently  be  found  in  the  stools  of  infants  who  do  not  show 
the  S3anptom-complex  characteristic  of  infectious  diarrhea.  From 
this  it  has  been  argued  that  the  gas  bacillus  is  not  a  cause  of  the 
disease,  but  that  its  presence  in  infectious  diarrhea  is  merely  acci- 
dental. The  same  argument,  however,  would  apply  to  the  pneumo- 
coccus  in  pneumonia,  as  it  is  frequently  found  in  the  sputum  of 
normal  individuals.  In  the  two  summers  when  the  gas  bacillus  was 
so  frequently  found  associated  with  the  infectious  diarrhea  prevalent 
in  Boston,  it  was  difficult  to  doubt  that  it  was  the  cause  of  the  disease. 
It  was  found  in  great  numbers  in  the  stools,  and  when  its  numbers 
diminished,  or  when  it  disappeared,  there  was  a  coincident  relief  of 
symptoms.  There  is  no  doubt  that  the  gas  bacillus,  and  similar 
organisms  may  frequently  be  present  in  the  stools  of  babies  who 
have  not  infectious  diarrhea.  It  is  also  strongly  probable  that  at 
times  these  organisms  may  develop,  invade  the  tissues,  and  produce 
lesions.     The  prevalence  of  gas  bacillus  infection,  and  indeed  of  any 


Infectious  Diarrhea  459 

particular  type  of  intestinal  infection,  probably  varies  in  different 
localities,  and  in  different  summers  in  the  same  locality. 

The  streptococcus  has  been  found  definitely  associated  with  cer- 
tain epidemics  of  infectious  diarrhea.  It  has  in  certain  cases  been 
demonstrated  in  the  tissues.  The  bacillus  pyocyaneus,  and  a  few 
other  organisms,  have  been  found  associated  with  the  lesions  of 
the  disease  in  rare  individual  instances. 

Causes  of  Infection. — The  manner  in  which  infection  occurs  in 
infectious  diarrhea  is  not  definitely  known.  Presumably  the  bac- 
teria are  taken  in  by  the  mouth,  and  consequently,  we  look  to  con- 
taminated food  as  the  vehicle  of  infection,  particularly  milk.  It  is 
known  that  milk  can  be  the  vehicle  of  infection,  but  it  is  not  proven 
in  just  what  proportion  of  cases  it  actually  plays  this  part.  The 
bacilli  may  also  be  carried  to  the  mouth  in  water,  on  the  hands,  or 
on  objects  put  in  the  child's  mouth.  There  is,  however,  some  evi- 
dence that  the  mere  entrance  of  the  pathogenic  microorganisms  into 
the  intestine,  or  their  presence  there,  does  not  necessarily  suffice  to 
cause  actual  infection.  By  infection  is  here  meant  invasion  of  and 
multipHcation  in  the  tissues.  The  various  bacteria  may  lead  a 
purely  saprophytic  existence,  without  invasion.  There  is  a  marked 
difference  of  opinion  among  authorities  as  to  the  circumstances  which 
cause  actual  infection  to  take  place.  One  view  is  that  a  sHght  lesion 
of  the  intestine,  such  as  might  be  caused  by  a  previous  digestive 
disorder,  is  essential.  The  other  view  also  regards  a  previous  diges- 
tive disorder  as  important,  but  holds  that  it  acts  by  altering  the 
chemical  composition  of  the  food  contents  in  the  intestine,  in  such 
a  way  as  to  produce  a  culture  medium  favorable  for  the  develop- 
ment of  the  organisms.  Whatever  the  final  mechanism  of  infection 
it  is  probable  that  the  introduction  of  organisms  from  without  is 
the  most  important  factor.  It  is  probable  also  that  the  precipitating 
cause  for  the  actual  infection  of  the  tissues  is  some  condition  in  the 
intestinal  contents,  such  as  indigestion,  which  provides  increased 
opportunity  for  bacterial  development,  or  some  lowering  of  the 
resistance  of  the  tissues  against  infection.  Given  such  favorable 
conditions,  the  introduction  of  bacteria  from  without  might  easily 
lead  to  infection,  or  infection  might  take  place  from  organisms  pre- 
viously introduced. 

Infectious  diarrhea  is  most  common  during  the  hot  months  of  the 
year.  This  may  be  explained  in  three  ways: — first,  that  hot  weather 
favors  the  development  of  microorganisms  outside  the  body,  in  milk 
and  other  food;  second,  that  it  is  in  hot  weather  that  indigestion,  with 
resulting  disturbance  of  the  character  of  the  intestinal  contents  most 
frequently  occurs;  third,  that  hot  weather  can  produce  a  marked 
lowering  of  resistance  against  infection.  The  relative  importance 
of  these  possible  factors  is  not  known. 


460  Diseases  of  the  Gastro-Enteric  Tract 

Infectious  diarrhea  is  most  common  in  artificially-fed  infants  and 
in  young  children.  The  period  when  it  occurs  most  frequently  is 
that  between  six  months  and  two  years.  It  is  not,  however,  by  any 
means  a  disease  confined  to  infants  and  young  children.  It  is  fre- 
quently seen  in  older  children,  and  may  even  occur  in  adults. 

PATHOLOGICAL  ANATOMY.— The  lesions  found  are  very 
varied.  The  variations  in  the  severity  of  the  tissue  changes  depend 
upon  two  factors,  first,  the  severity  of  the  infection,  and  second,  the 
duration  of  the  infection  before  death  occurs.  The  slightly  marked 
pathological  tissue  changes  are  found  in  feeble  infants  who  succumb 
to  a  comparatively  mild  infection,  or  in  patients  who  succumb  almost 
immediately  to  a  severe  infection.  The  more  marked  lesions  are 
found  in  patients  w^ho  resist  a  severe  infection  for  a  considerable  time. 

In  the  milder  cases  there  may  be  only  catarrhal  inflammation  of 
the  mucosa.  In  the  cases  which  die  rapidly  from  a  severe  infec- 
tion, there  may  be  only  shght  h}"perplasia  of  the  Ijonphatic  tissue. 
In  other  cases,  in  which  the  duration  of  hfe  has  been  longer,  there 
is  very  extensive  h}^erplasia  of  the  sohtary  foUicles  and  Peyer's 
patches.  In  this  type  there  may  be  only  a  few  small  ulcers  on  the 
h}^erplastic  l}Tiiphoid  tissue,  or  there  may  be  extensive  ulceration. 
In  more  severe  cases  not  immediately  fatal,  there  may  be  a  super- 
ficial necrosis  of  the  whole  mucosa.  FinaUy,  there  may  be  an  ex- 
tensive pseudomembrane,  consisting  of  necrotic  tissue,  leukocytes, 
and  bacteria,  but  ^\ith  little  or  no  fibrin. 

The  lesions  are  usually  Hmited  to  the  colon  and  the  lower  portion 
of  the  ilium.     They  are  ordinarily  most  marked  in  the  colon. 

There  is  usually  some  hyperplasia,  and  slight  congestion  of  the 
mesenteric  lymph  nodes.  There  are  often  degenerative  lesions  in  the 
liver  and  kidneys.  Secondary  infections,  such  as  otitis  media,  bron- 
chitis, bronchopneumonia,  and  pyeHtis,  due  to  diminished  resistance, 
are  seen  at  times. 

SYMPTOAIS. — The  principal  symptoms  are  diarrhea,  fever,  toxe- 
mia, and  rapid  loss  of  weiglit. 

Typical  Cases. — The  onset  is  usually  acute.  In  some  cases 
symptoms  of  some  form  of  indigestion  precede  the  symptoms  of 
infection.  Occasionally  the  symptoms  of  infection  develop  after  a 
preceding  diarrhea  characteristic  of  indigestion  or  fermentation. 
Usually,  however,  there  are  no  premonitory  s}Tiiptoms. 

Diarrhea  is  ordinarily  the  first  symptom.  The  first  evacuations 
consist  of  fecal  matter,  but  in  typical  cases,  mucus  and  blood  soon 
appear.  Soon  after  this,  sometimes  in  a  few  hours,  sometimes  not 
for  one  or  two  days,  the  stools  become  mainly  composed  of  mucus 
and  blood,  with  little  or  no  fecal  matter.  The  mucus  may  be  white, 
but  is  often  stained  green  or  brown.     The  amount  of  blood  is  very 


Infectious  Dla.rrhea 


461 


Fig.  99 


Non-ulcerative  follicular  inflammation.     Simple  hyperplasia  of  lymph-follicles. 
Female,  3  years  old.     Warren  Museum,  Harvard  University 


462  Diseases  of  the  Gastro-Exteric  Tract 

Fig.  ioo 


Colitis  follicularis  non-ulcerative.     Male,  2  years  old.     ^Museum  of  the  College 
of  Physicians  and  Surgeons,  New  York 


Infectious  Diarrhea 

Fig.  ioi 


463 


Inflammation  of  follicles  and  surrounding  p;uL^  n\  i  olun.      Ihe  process  has  gone  on  to 
necrosis.     Female,  3  months  old.     Warren  Museum,  Harvard  University 


464 


Diseases  of  the  Gastro-Enteric'^Tract 

Fig.  I02 


Pigmented  follicular  ulcers  of  colon.     Chronic  catarrhal  ulcerative  follicular  colitis. 
Museum  of  the  College  of  Physicians  and  Surgeons,  New  York 


Infectious  Diarrhea 

Fig.  103 


465 


(.'01  it  is  follicularis  non-ulccrati\'a 


30 


466  Diseases  of  the  Gastro-Enteric  Tract 

Fig.  104 


Pseudo-membranous  colitis.     Cliild,  iH  years  old.     Museum  of  the  College 
of  Ph^'sicians  and  Surgeons,  New  York 


Infectious  Diarrhea 

Fig.  105 


467 


Acute  ulcerative  catarrhal  colitis.     Female,  3  months  old.     Museum  of  the 
College  of  Physicians  and  Surgeons,  New  York 


468 


Diseases  of  the  Gastro-Enteric  Tract 

Fig.  io6 


Ileo-colitis  ulcerativa  follicularis.     Infant,  i6  months  old._    Museum  of  the 
College  of  Physicians  and  Surgeons,  New  \ork 


Infectious  Diarrhea  469 

variable;  sometimes  only  specks  of  blood  are  seen,  while  in  other 
cases  the  mucus  is  profusely  streaked  with  blood,  and  in  still  other 
cases  there  is  considerable  blood-stained  mucus.  The  blood  never 
is  homogeneously  mixed  with  the  mucus,  as  in  intussusception,  but 
there  is  always  some  mucus  which  is  not  blood-stained.  While  blood 
is  present  in  the  great  majority  of  cases,  there  are  occasionally  cases 
which  have  been  found  to  be  caused  by  the  dysentery  bacillus,  in 
which  no  blood  appeared  in  the  stools.  Pus  cells  can  usually  be 
found  microscopically;  macroscopically  pus  may  never  be  seen,  or 
may  appear  after  a  few  days.  Membrane  is  only  present  in  the  sever- 
est cases.  The  stools  usually  have  very  little  odor,  unless  there  is 
membrane  or  much  pus  present,  when  they  may  have  a  putrefactive 
odor.  The  reaction  of  the  stools  is  not  constant,  but  in  the  majority 
of  cases  it  is  alkaline.  The  number  of  stools  passed  in  twenty-four 
hours  is  very  variable,  and  bears  no  definite  relation  to  the  toxic 
severity  of  the  case.  The  number  may  vary  from  twelve  to  forty 
or  more  in  twenty-four  hours.  When  the  evacuations  are  frequent, 
the  stools  are  usually  very  small,  often  consisting  of  no  more  than  a 
small  stain  of  mucus  and  blood. 

Fever  is  a  constant  symptom  of  infectious  diarrhea.  The  tem- 
perature usually  runs  between  ioo°  F.  and  102°  F.,  but  may  be 
several  degrees  higher.  The  temperature  curve  does  not  usually 
show  marked  exacerbations  and  remissions.  It  is  a  fairly  accurate 
measure  of  the  progress  of  the  infection,  tending  to  rise  when  the 
patient  gets  worse,  and  to  come  down  when  the  patient  is  improving. 
The  fever  persists  throughout  the  active  stage  of  the  disease. 

Toxic  symptoms  are  present  in  the  severer  cases,  absent  in  the 
milder  ones.  Various  factors  may  produce  the  toxemia.  It  may  be 
due  to  the  absorption  of  bacterial  endotoxines,  and  that  this  cause 
certainly  plays  a  part  is  strongly  suggested  by  the  fact  that  in  dysen- 
tery infection,  agglutinins  and  bacteriolysins  are  formed  in  the  blood. 
The  toxemia  may  be  caused  by  the  loss  of  water  and  salts,  as  in 
fermental  diarrhea,  but  the  case  symptoms  do  not  usually  suggest  a 
relative  acidosis.  It  is  probable  that  in  dysentery  infection,  at  least, 
the  toxemia  is  mainly  of  bacterial  origin. 

The  commonest  manifestation  of  toxemia  is  a  clouded  mentality, 
the  patients  being  dull,  and  reacting  very  little  to  their  surround- 
ings. In  severe  cases  their  stupor  is  deeper;  they  may  be  com- 
pletely comatose  and  relaxed.  At  any  time  in  these  severe  cases 
marked  prostration  or  sudden  collapse  is  liable  to  occur. 

There  may  be  toxic  symptoms  referable  to  irritation  of  the  central 
nervous  system.  Restlessness,  twitching  of  the  extremities,  and 
sometimes  even  convulsions  may  occur.  The  signs  of  meningeal 
irritation  may  be  so  marked  as  to  suggest  a  meningitis.  Any  of  the 
so-called  meningeal  symptoms,  such  as  rigidity  of  the  neck,  retrac- 


470  Diseases  of  the  Gastro-Enteric  Tract 

tion  of  the  head,  inequaHty  of  the  pupils,  exaggeration  of  the  knee- 
jerks,  Kernig's  sign,  and  so  forth,  may  be  present. 

Abdominal  pain  is  a  common  symptom,  and  appears  early  in  the 
course  of  the  disease.  It  appears  to  be  most  severe  when  the  patient 
is  having  an  evacuation  of  the  bowels.  Tenderness  of  the  abdomen 
is  almost  never  seen;  occasionally  there  is  slight  tenderness  along  the 
course  of  the  colon,  but  involuntary  muscular  spasm  is  almost  never 
present.  The  abdomen  is  markedly  retracted  in  the  majority  of 
cases.  Occasionally,  however,  there  may  be  abdominal  distention. 
The  liver  and  spleen  are  occasionally  enlarged,  but  this  condition  is 
not  common  enough  to  be  in  any  way  characteristic. 

Tenesmus  is  frequently  present,  and  may  be  a  particularly  annoy- 
ing symptom.  Prolapse  of  the  rectum  from  the  constant  straining 
is  not  uncommon. 

Vomiting  is  not  a  prominent  symptom  in  typical  cases.  It  is 
often  absent,  and  when  it  does  occur,  it  is  not  usually  severe  enough 
to  be  troublesome.  The  appetite  is  usually  very  much  impaired, 
and  it  is  often  difficult  to  get  patients  with  infectious  diarrhea  to 
take  sufficient  nourishment.     Loss  of  weight  is  very  marked. 

The  urine  is  diminished  in  quantity  and  concentrated.  Casts,  and 
a  small  amount  of  albumen  are  often  present,  pointing  toward  degen- 
eration of  the  renal  epithelium.  Sugar  is  usually  not  found  in  the 
urine,  unless  a  large  amount  is  being  given  in  the  food,  and  even 
then  not  constantly. 

The  blood  usually  shows  a  leukocytosis.  The  white  count  is  ordi- 
narily about  2o,,ooo,  but  may  be  higher.  In  some  cases,  particularly 
very  severe  ones  with  marked  toxemia,  the  white  blood  count  may  be 
normal,  or  even  diminished. 

Atypical  Cases. — The  most  common  atj^ical  symptom-complex 
seen  in  infectious  diarrhea  is  the  very  mild  one.  In  this  t5^e,  the 
diarrhea  is  not  severe,  and  the  appearance  of  the  stools  is  not  char- 
acteristic. The  daily  number  of  evacuations  may  be  very  little  in- 
creased, there  being  sometimes  no  more  than  four  to  six  bowel  move- 
ments in  twenty-four  hours.  Blood  may  be  wholly  absent,  mucus 
may  not  be  excessive  in  amount,  and  fecal  matter  may  be  present 
throughout,  and  may  present  appearances  suggesting  various  forms 
of  indigestion.  Abdominal  pain  and  tenesmus  are  absent  in  this 
mild  type.  Fever,  however,  is  usually  present  and  continued,  even 
though  moderate.  Some  mucus  visible  macroscopically,  is  usually 
constantly  present  in  the  stools. 

Another  atypical  symptom-complex  is  seen  in  very  severe  cases, 
which  end  fatally  before  characteristic  symptoms  have  had  time  to 
develop.  These  cases  resemble  severe  cases  of  acute  indigestion  with 
fermentation.  With  or  without  premonitory  symptoms  of  indiges- 
tion, severe  diarrhea  develops,  accompanied  by  high  fever,  and  marked 


Infectious  Diarrhea  471 

toxic  symptoms.  The  stools  are  watery,  and  do  not  contain  blood, 
or  excessive  mucus.  Severe  prostration,  followed  by  collapse  and 
death  end  the  disease,  usually  within  twenty-four  hours.  Cases  of 
this  type,  even  on  post-mortem  examination,  resemble  fermental 
diarrhea  in  that  they  show  very  little  pathological  change  in  the 
intestinal  mucosa.  They  are  recognized  as  a  type  of  infectious 
diarrhea  only  because  the  dysentery  bacillus  has  been  found  in  great 
numbers  in  the  intestinal  discharges. 

Other  cases  are  atypical  only  in  the  exaggerated  severity  of  some 
particular  symptom.  Hyperpyrexia  is  seen  occasionally.  In  rare 
cases,  vomiting  is  excessive.  In  other  cases,  meningeal  symptoms 
are  unusually  pronounced. 

DIAGNOSIS. — In  typical  cases  of  infectious  diarrhea  the  symp- 
tom-complex is  so  characteristic,  that  little  difficulty  attends  the 
diagnosis.  The  only  other  condition  characterized  by  stools  con- 
taining blood  and  excessive  mucus,  is  intussusception.  Atypical  cases, 
however,  may  be  mistaken  for  simple  indigestion  from  overfeeding, 
for  indigestion  with  fermentation,  and  for  meningitis. 

Intussusception  begins  usually  with  abdominal  pain  and  symptoms 
of  more  or  less  shock,  whereas  infectious  diarrhea  begins  with  frequent 
loose  movements,  abdominal  pain  not  being  so  prominent,  and  shock- 
being  absent.     In  both  conditions  the  first  stools  contain  fecal  matter; 
in  infectious  diarrhea,  while  some  stools  may  consist  entirely  of  mucus- 
and  blood,  other  stools  contain  some  fecal  matter.     In  infectious  diar- 
rhea the  mucus  and  blood  appear  somewhat  earlier  in  the  stools,  and 
diarrhea  is  usually  a  more  prominent  symptom.     In  intussusception 
the  blood  and  mucus  are  homogeneously  mixed,  all  the  mucus  being 
blood-stained,  often  resembling  currant  jelly;  in  infectious  diarrhea 
there  is  always  some  unstained  mucus,  and  the  stools  do  not  have 
the  currant  jelly  appearance.     Fever  may  be  present  or  absent  in 
intussusception,  while  in  infectious  diarrhea  it  is  always  present,  and 
is  usually  higher  than  in  intussusception.     The  abdomen  in  infec- 
tious diarrhea  is  usually  retracted,  and  on  palpation,  involuntary 
muscular  spasm  is  never  present.     In  intussusception,  the  abdomen 
is  usually  somewhat  distended,  and  involuntary  muscular  spasm  is 
often  present.     In  infectious  diarrhea  no  tumor  can  be  recognized 
either  by  abdominal  palpation  or  by  rectal  examination;  in  intussus- 
ception a  tumor  can  often  be  found,  although  the  absence  of  a  tumor 
does  not  positively  rule  it  out.     The  important  thing  to  remember 
is,  that  in  order  not  to  overlook  intussusception,  a  diagnosis  of  infectious 
diarrhea  should  never  he  made  without  an  actual  inspection  of  the  stools, 
and  a  careful  examination  for  tumor. 

Simple  indigestion  from  relative  excess  of  food  manifests  itself  very 
often  in  summer  by  an  acute  diarrhea.     It  is  sometimes  difficult  to 


472  Diseases  of  the  Gastro-Enteric  Tract 

distinguish  very  mild  infectious  diarrhea,  in  which  the  daily  number 
of  stools  is  not  very  large,  and  in  which  blood  is  absent  and  mucus 
small  in  amount,  from  acute  diarrhea  due  to  simple  indigestion.  The 
chief  differential  feature  is  the  fever,  which  is  always  constantly 
present,  even  though  moderate,  in  infectious  diarrhea,  and  is  never 
constantly  present  in  indigestion.  Nevertheless,  in  many  of  these 
mild  cases  of  infectious  diarrhea  the  diagnosis  is  not  made  for  a 
considerable  time,  the  physician  making  repeated  careful  physical 
examinations  in  the  effort  to  account  for  the  fever  by  finding  some 
disease  process  outside  the  intestinal  canal.  In  such  cases  the  diag- 
nosis can  sometimes  only  be  made  by  means  of  a  bacteriological 
examination  of  the  stools.  In  other  cases  the  correct  diagnosis  is 
finally  suspected  when  the  patient  responds  to  the  treatment  for 
infectious  diarrhea. 

There  is  a  form  of  intestinal  disturbance  which  can  only  be  classi- 
fied under  simple  indigestion,  which  is  occasionally  seen  when  some 
very  unusually  indigestible  and  irritating  substance  is  eaten.  I  have 
seen  it  produced  in  babies  by  the  giving  of  such  things  as  green  corn, 
pickles,  and  cucumbers.  In  this  condition  diarrhea  may  occur  with 
mucus  and  blood  in  the  stools.  It  is  distinguished  from  infectious 
diarrhea  by  the  absence  of  fever,  the  history  of  some  gross  dietary 
indiscretion,  and  the  rapid  response  to  treatment. 

Indigestion  with  fermentation  is  very  difficult  to  exclude  in  certain 
cases  of  infectious  diarrhea.  The  difficulty  of  diagnosis  occurs  both 
in  the  very  severe  type  of  infectious  diarrhea  in  which  death  occurs 
before  characteristic  stools  have  developed,  and  also  in  the  mild 
type  in  which  blood  does  not  appear  in  the  stools.  Diarrhea,  fever, 
wasting,  and  toxic  symptoms  are  seen  in  both  conditions,  and  a 
positive  diagnosis  is  often  impossible.  When  the  amount  of  mucus 
in  the  stools  is  large,  the  evidence  points  toward  infectious  diarrhea. 
The  most  important  point  in  differential  diagnosis  is  the  character 
of  the  temperature  curve.  In  fermental  diarrhea,  the  temperature 
is  usually  higher  at  the  onset,  and  falls  in  one  or  two  days;  it  often 
reaches  the  normal  before  the  symptoms  are  relieved.  In  infectious 
diarrhea,  the  temperature  may  not  be  so  high  at  the  onset,  but  is 
more  steadily  maintained,  and  some  fever  persists  throughout  the 
active  stage  of  the  disease.  In  many  cases,  however,  a  positive  diag- 
nosis can  only  be  made  by  a  bacteriological  examination  of  the  stools. 

There  are  cases  in  which  stools  resembling  infectious  diarrhea,  and 
containing  mucus  and  blood,  are  seen  after  prolonged  simple  indi- 
gestion, or  prolonged  indigestion  with  fermentation.  These  cases  are 
often  misleading.     They  are  recognized  by  the  absence  of  fever. 

Meningitis  is  suspected  when  the  signs  of  meningeal  irritation  are 
pronounced.  When  severe  diarrhea  with  characteristic  discharges 
are  present,  the  meningeal  symptoms  are  easily  explained  by  the 


Infectious  Diarkeiea  473 

intestinal  infection.  When  the  intestinal  symptoms  are  not  marked, 
or  when  characteristic  stools  have  not  developed,  the  diagnosis  may 
be  doubtful.     In  such  cases  a  lumbar  puncture  will  settle  the  diagnosis. 

Bacteriological  Examination  of  the  Stools. — A  practical, 
speedy,  and  fairly  accurate  method  for  determining  the  presence  of 
the  gas  bacillus  is  the  "stormy  fermentation"  test.  Litmus  milk  or 
sterile  fat-free  milk  is  inoculated  with  a  loopful  of  feces,  heated  to 
80°  C.  in  a  water  bath  for  twenty  minutes,  and  then  incubated  twenty- 
four  hours.  If  no  spores  are  present,  there  will  be  no  growth  in  the 
tube,  and  the  milk  will  be  unchanged.  If  the  spores  of  a  gas  form- 
ing bacillus  such  as  the  bacillus  Welchii  are  present  the  milk  will 
show  a  tough  clot,  permeated  with  gas  holes  and  often  "driven" 
against  the  side  of  the  tube  or  to  the  surface  of  the  media;  there 
will  be  marked  acid  formation,  the  fluid  residue  will  be  compara- 
tively clear,  much  of  the  casein  will  be  dissolved  and  the  culture 
will  have  a  distinct  odor  of  butyric  acid. 

The  isolation  and  identification  of  the  dysentery  bacillus  is  not 
always  an  easy  matter.  Only  material  from  very  recently  passed 
stools  should  be  used.  A  suspension  of  the  feces  in  bouillon  is  first 
made,  the  amount  used  being  a  variable  quantity.  If  there  be 
macroscopic  pus  present  in  the  stool,  one  loopful  to  a  small  tube 
of  bouillon  may  be  used;  two  or  more  loopfuls  of  mucus  may  be 
used  when  no  pus  is  found.  One  should  attempt  in  all  cases  to  secure 
pus  or  mucus  for  the  suspension.  This  emulsion  should  be  streaked 
by  means  of  a  glass  rod  over  Endo-plates  (prepared  from  a  2%  agar), 
and  the  plates  incubated  from  sixteen  to  twenty-four  hours.  Suspi- 
cious colonies  will  appear  as  small,  circular,  translucent,  bluish-gray 
drops,  not  causing  discolorization  of  the  media.  Bouillon  tubes  are 
inoculated  from  such  colonies  and  incubated  six  hours.  Then  stab- 
cultures  are  made  in  three  tubes  of  Hiss'  semi-solid  media,  one  con- 
taining lactose,  one  glucose,  and  one  mannit,  litmus  being  added  as 
an  indicator.  They  are  incubated  twelve  hours  and  then  examined 
for  motility,  and  for  gas  and  acid  production.  The  organisms  should 
be  small,  gram-negative  bacilli,  non-motile,  forming  acid  from  dex- 
trose, and  not  acting  upon  lactose,  nor  forming  gas.  The  formation 
of  acid  from  mannit  will  further  differentiate  the  organism  of  the 
so-called  mannit-fermenting  group  of  dysentery  bacillus  (Flexner 
type).  Agglutination  tests  may  then  be  done  with  those  bouillon 
tube  cultures,  in  which  the  organisms  have  resembled  the  dysentery 
bacillus.  The  serum  is  obtained  from  the  Rockefeller  Institute  for 
Medical  Research  and  is  prepared  only  for  the  mannit-fermenting 
strains.  It  should  be  diluted  to  1/500  and  the  test  made  by  mixing 
in  small  tubes  i  c.c.  of  the  serum  and  i  c.c.  of  the  culture,  the  fluid 
diluted  i/iooo;  a  control  with  normal  saline  is  made  in  each  case. 
The  agglutination  tubes  are  incubated  two  hours,  and  then  set  in 


474  Diseases  of  the  Gastro-Exteric  Tract 

a  cold  glass  jar  for  twelve  to  twenty-four  hours.  Sometimes  the 
phenomenon  can  be  determined  at  the  end  of  the  incubation;  by 
observing  through  a  hand  lens  the  formation  of  small  fiocculent 
masses.  Usually  it  is  necessary  to  wait  until  the  masses  have  set- 
tled, after  the  tubes  have  remained  some  hours  in  the  ice-chest. 
Here,  if  the  test  be  positive,  the  masses  are  seen  clinging  to  the  sides 
of  the  tubes,  or  forming  a  sediment  at  the  bottom,  the  rest  of  the 
tube  being  clear  as  compared  with  the  control,  which  is  cloudy. 

PROGNOSIS. — Infectious  diarrhea  is  the  most  serious  of  aU  the 
acute  diarrheal  diseases  of  early  life.  The  mortality  varies  greatly 
in  different  localities,  and  in  different  summers.  In  a  series  of  cases 
studied  at  the  Infant's  Hospital  in  Boston,  including  only  82  cases, 
the  mortahty  was  14.5  %.  In  the  report  of  Flexner  and  Holt,  in- 
cluding only  cases  in  which  the  bacillus  of  dysentery  was  found,  the 
mortality  ia  207  cases  was  35%. 

From  the  beginning  of  a  case  of  infectious  diarrhea,  the  prognosis 
should  always  be  guarded.  Older  children  have  a  better  chance  than 
infants,  but  the  end  can  never  be  definitely  predicted.  Death  may 
foUow  early  in  the  course  of  the  disease,  but  occurs  most  commonly 
in  the  second  week,  and  may  be  delayed  for  a  longer  period.  In  the 
cases  which  recover,  improvement  is  usually  seen  by  the  end  of  the 
first  week,  or  by  the  beginning  of  the  second.  In  some  cases,  however, 
no  improvemient  may  be  seen  for  several  weeks.  The  disease  tends 
to  run  a  rather  long  course,  improvement  is  slow,  relapses  are  com- 
mon, and  the  management  of  the  feeding  is  difficult.  The  presence 
of  symptoms  of  severe  toxemia  is  a  serious  prognostic  sign. 

TREAT^SIEXT.  PRELniiXARY. — The  first  step  in  the  treatmient 
of  a  case  of  diarrhea  is  to  cleanse  the  intestinal  tract  of  accumulated 
mucus,  and  fermenting  food  products.  This  is  best  accompHshed  by 
means  of  castor  oil,  which  is  the  most  thorough  and  least  irritating 
of  the  cathartics.  One  teaspoonful  may  be  given  to  infants  in  the 
first  three  months,  two  teaspoonfuls  from  three  to  eighteen  months, 
and  three  teaspoonfuls  to  older  infants.  Children  should  take  from 
a  dessertspoonful  to  a  tablespoonful  according  to  age.  If  the  castor 
oil  is  vomited,  calomel  should  be  given,  to  babies  in  the  first  year 
in  doses  of  one-tenth  of  a  grain  every  half-hour  for  ten  doses,  and 
in  the  second  year  in  doses  of  one-fourth  of  a  grain  every  half-hour 
for  six  doses,  and  to  older  children  in  doses  of  one-fourth  of  a  grain 
every  half-hour  for  eight  doses.  Two  hours  after  the  last  dose,  two 
or  three  teaspoonfuls  of  milk  of  magnesia  should  be  given. 

From  the  time  of  giving  the  castor  oil,  or  of  beginning  the  calomel, 
the  giving  of  all  food  should  be  stopped  for  from  twelve  to  twenty- 
four  hours.  During  this  period  water  must  be  given  freely,  in  a 
quantity  at  least  equal  to  the  quantity  of  fluid  which  the  patient 


Infectious  Diarrhea  475 

would  take  if  it  were  receiving  its  ordinary  food.  The  water  may  be 
given  with  the  bottle,  or  from  a  cup,  as  preferred  by  the  child,  and 
may  be  either  warm  or  cool,  according  to  the  taste  of  the  child.  If 
sufficient  water  be  not  taken,  it  must  be  given  with  a  spoon,  and  if 
there  is  still  difficulty  in  getting  in  the  desired  quantity,  it  must  be 
given  through  a  tube.  It  may  be  sweetened  with  saccharin,  if  taken 
better  that  way. 

The  length  of  the  period  of  withholding  food  should  not  be  longer 
than  twenty-four  hours. 

The  Feeding. — The  diet  in  infectious  diarrhea  is  difficult  to  pre- 
scribe. All  wTiters  agree  that  the  management  of  the  feeding  is  a 
matter  of  the  greatest  importance  in  the  treatment  of  the  disease. 
Nevertheless,  the  most  diverse  views  as  to  what  the  diet  should  be 
are  advanced  by  various  authorities.  The  two  principal  views  on 
the  diet  are  diametrically  opposed.  According  to  one  view  the 
diet  should  be  high  in  fermentable  sugar  and  low  in  protein.  Ac- 
cording to  the  other  view  the  diet  should  be  high  in  protein  and 
comparatively  low  in  sugar.  In  addition  to  these  two  opposed  views, 
some  authorities  believe  that  the  food  should  be  very  low  in  fat 
content,  while  others  advocate  feeding  with  such  substances  as  albu- 
men water,  beef  juice,  and  whey. 

The  view  that  the  diet  should  be  chiefly  carbohydrate  is  based  on 
certain  bacteriological  studies.  The  bacillus  dysenteriae,  the  strep- 
tococcus, and  the  other  organisms  except  the  gas  bacillus  which  have 
been  associated  with  infectious  diarrhea,  have  been  shown  to  belong 
to  the  facultative  group  which,  when  living  on  carbohydrate,  pro- 
duces harmless  products,  but  which  in  the  absence  of  sufficient  car- 
bohydrate attacks  the  protein,  with  the  formation  of  toxic  products. 
Further,  the  products  of  carbohydrate  fermentation  have  a  certain 
inhibitory  action  on  the  development  of  the  bacillus  of  dysentery. 
Those  who  believe  that  these  facts  about  the  cultural  peculiarities 
of  the  dysentery  bacillus  should  be  the  basis  of  treatment,  advocate 
beginning  feeding  with  a  5%  or  6%  solution  of  lactose  in  barley 
water,  and  gradually  adding  protein  by  means  of  the  addition  of 
fat-free  milk.  The  advocates  of  this  view  also  recommend  attack- 
ing the  bacilli  which  have  entered  the  tissues  by  means  of  a  dextrose 
solution  given  intravenously. 

The  objections  to  this  theoretical  basis  of  dietary  treatment  are 
numerous.  In  the  first  place,  even  when  an  excessive  quantity  of 
lactose  is  given  in  the  food,  practically  none  is  excreted  in  the  feces. 
The  unabsorbed  excess  is  all  destroyed  by  the  fermentation  of  the 
normal  intestinal  bacteria,  and  this  destruction  certainly  takes  place 
in  the  upper  part  of  the  intestinal  canal,  above  the  colon  which  is 
the  chief  seat  of  the  disease.  Consequently,  it  is  probable  that  no 
sugar  reaches  the  dysentery  bacilli.     Even  if  lactose  did  enter  the 


476  Diseases  of  the  Gastro-Enteric  Tract 

colon  and  lower  part  of  the  ileum,  or  even  if  the  products  of  lac- 
tose fermentation  are  inhibitory  toward  the  development  of  the 
bacillus  of  dysentery,  the  organisms  which  are  causing  the  disease 
are  not  in  the  intestinal  contents,  but  have  penetrated  into  the 
tissues,  where  they  can  easily  find  all  the  protein  they  need.  As  to 
the  giving  of  dextrose  solution  by  intravenous  injection,  it  is  difiicult 
to  see  how  it  can  have  an  effective  action  against  the  bacilli  which 
have  penetrated  the  tissues.  The  evidence  shows  that  the  dextrose 
is  rapidly  utihzed  or  excreted  in  the  urine,  and  consequently  very 
little  if  any  can  reach  the  microorganisms,  which  are  already  sur- 
rounded by  protein  tissue. 

It  seems  to  me  that  this  theoretical  basis  for  the  feeding  of  infec- 
tious diarrhea,  while  attractive,  involves  too  great  an  assumption 
as  to  what  goes  on  inside  the  body.  Proof  is  entirely  lacking  that 
the  conditions  which  influence  the  development  of  the  bacteria  in 
vitro  can  be  in  any  way  reproduced  within  the  body  of  the  host. 

The  advocates  of  the  opposing  view  believe  that  the  food  should 
be  high  in  protein,  and  many  of  them  recommend  albumin  milk  in 
the  feeding  of  infectious  diarrhea.  This  view  is  based  on  the  un- 
doubted fact  that  the  dangers  from  the  casein  of  cow's  milk  have 
been  greatly  exaggerated.  It  is  also  based  on  Finkelstein's  theory 
of  the  dangers  of  carbohydrate  in  severe  gastro-intestinal  disorders — 
the  idea  of  sugar  intoxication.  The  objection  to  the  view  is  that  it 
takes  a  disease  which  is  admittedly  bacterial  in  origin,  and  then  for 
its  treatment  applies  a  theory  which  attributes  gastro-intestinal 
disease  exclusively  to  chemical  causes.  It  is  certain  that  the  theory 
of  sugar  intoxication  has  been  disproved.  The  advocates  of  albumin 
milk  have  shifted  their  ground  by  attributing  the  dangers  of  car- 
bohydrate— the  so-called  "pyrogenic  action"  of  sugar — to  increased 
carbohydrate  fermentation.  But  why  the  necessity  of  attributing 
the  fever  to  the  sugar  in  a  disease  manifestly  caused  by  bacteria,  of 
which  the  products  on  any  culture  medium  are  toxic?  The  advo- 
cates of  low  carbohydrate,  however,  do  not  in  general  make  the 
same  distinction  between  fermental  diarrhea  and  infectious  diarrhea 
which  is  made  here.  There  is  no  doubt  that  protein  is  necessary 
for  the  metabolism  of  children  with  infectious  diarrhea  as  well  as  for 
that  of  children  in  general.  The  favorable  results  of  feeding  with 
albumin  milk  can  easily  be  explained  by  the  fact  that  this  food  is 
easily  digestible.  It  is  comparatively  low  in  fat  and  sugar,  and 
the  casein  is  in  a  finely  divided  and  easily  digested  form. 

The  view  that  fat  should  be  excluded  from  the  food,  or  should  be 
very  small  in  amount,  is  based  on  the  difficulty  of  digesting  and 
absorbing  fat  in  severe  gastro-intestinal  disorders.  It  is  partly 
due  to  the  effect  of  the  Finkelstein  teaching,  which  fails  to  distinguish 
clearly  between  the  break-down  of  metabolism  and  nutrition  which 


Infectious  Diarrhea  477 

occurs  as  a  final  result  in  a  chronic  disturbance  of  digestion,  and  a 
primary  bacterial  infection  such  as  I  believe  infectious  diarrhea  to 
be.  I  believe  that  the  difficulty  of  absorbing  fat,  and  the  consequent 
disturbance  of  metabolism,  has  been  greatly  exaggerated  in  con- 
nection with  infectious  diarrhea. 

The  view  that  such  foods  as  whey,  albumen  water,  and  beef  juice 
should  be  used  in  infectious  diarrhea  is  based  on  the  theory  that 
in  these  foods  the  soluble  protein  is  more  easily  digested  than  the 
insoluble  casein,  and  that  consequently  these  foods  leave  less  residue 
to  act  as  irritants  to  the  inflamed  mucus  membrane.  This  same 
theory  once  dominated  the  treatment  of  typhoid  fever,  but  has  now 
almost  entirely  been  relegated  to  oblivion  in  that  disease.  There  is 
at  present  little  disagreement  as  to  the  ordinary  digestibility  of 
casein,  while  there  is  considerable  evidence  pointing  toward  possible 
danger  from  the  albumins. 

It  is  a  very  significant  fact  that  the  advocates  of  all  these  views 
are  enthusiastically  in  favor  of  their  particular  theory  of  treatment, 
and  report  superior  results  from  its  use.  This  I  think  strongly 
suggests  that  in  infectious  diarrhea,  no  particular  dietary  treatment 
based  on  theoretical  grounds  is  of  special  value.  The  results  seem  to 
be  about  equally  good  or  bad,  whatever  theory  of  diet  is  put  into 
practice.  I  have,  in  my  own  wards  tried  alternately  the  high  sugar 
treatment,  and  albumen  milk,  and  have  never  seen  the  slightest 
evidence  that  the  one  method  is  superior  to  the  other  in  the  treat- 
ment of  infectious  diarrhea  in  general.  /  do  7tot  believe  that  altera- 
tions in  the  diet  to  fit  any  theory  have  any  specific  influence  on  the 
progress  of  the  infection. 

How,  then,  shall  we  feed  cases  of  infectious  diarrhea?  I  believe 
that  the  feeding  should  be  governed  by  the  same  principles  as  govern 
the  feeding  of  any  acute  infection,  such  as,  for  instance,  typhoid  fever. 
Indeed,  infectious  diarrhea  seems  to  me  to  be  much  more  closely 
related  to  typhoid  fever  than  to  the  simple  disturbances  of  diges- 
tion, or  to  indigestion  with  fermentation  in  the  intestinal  contents. 
It  is  only  in  the  latter  disease  that  the  composition  of  the  food  is 
all-important  in  its  influence  on  the  actual  processes  which  cause  the 
disease.  In  infectious  diarrhea,  as  in  typhoid  fever,  the  symptoms 
are  caused  by  true  parasites,  which  invade  the  tissues,  produce 
lesions,  produce  toxins,  and  against  which  the  host  elaborates  im- 
mune bodies.  Diseases  of  this  kind  recover,  not  by  alterations  of 
the  chemical  contents  of  the  intestine,  but  through  the  development 
of  resistance  on  the  part  of  the  patient.  Our  aim  in  feeding,  there- 
for, in  infectious  diarrhea  as  in  any  acute  disease,  should  be  to  nourish 
the  patient  as  well  as  possible,  in  order  to  increase  his  power  of 
resistance  against  infection. 

How  this  aim  is  carried  out  in  practice  depends  on  the  digestive 


478  Diseases  of  the  Gastro-Enteric  Tract 

peculiarities  of  the  particular  case.  In  infants  the  disease  is  com- 
plicated by  various  forms  of  digestive  disturbance,  and  our  manage- 
ment of  the  feeding  should  be  that  of  any  difficult  case  of  infant 
feeding.  We  give  the  infant  what  we  think  it  can  digest,  and  alter 
the  composition  of  the  food  to  meet  the  indications  as  they  arise, 
guided  in  our  changes  by  the  character  of  the  stools,  and  the  various 
symptoms  of  indigestion.  In  older  children  dilute  milk,  soluble 
carbohydrate,  beef  juice,  and  albumin  water  all  have  their  place. 
As  convalescence  approaches,  gruels  may  be  added. 

One  exception  to  the  theory  of  treatment  outlined  above  should 
be  noted.  There  is  a  probability  that  the  symptoms  may  be  caused 
by  the  gas  bacillus.  It  has  been  shown  by  Tissier  and  others  that 
the  lactic  acid  bacillus  inhibits  the  growth  of  the  strain  of  gas  bacillus 
known  as  the  bacillus  perfringens.  There  is  evidence  that  the  favor- 
able effect  of  the  lactic  acid  bacillus  can  be  realized  in  the  intestine. 
Therefore,  theoretically,  the  lactic  acid  bacillus  should  be  given  to  cases 
of  gas  bacillus  infection.  Unfortunately,  however,  as  explained  under 
Diagnosis,  we  can  never  be  sure  when  the  symptoms  are  due  to  the 
gas  bacillus.  The  finding  of  a  positive  test  for  gas  bacilli  in  the 
stools  is  not  positive  proof  of  their  etiological  importance.  Still, 
fat-free  milk  ripened  with  a  known  strain  of  lactic  acid  bacillus  is 
a  digestible  food,  and  would  not  be  contraindicated  in  dysentery 
infection.  It  differs  from  the  widely  recommended  albumin  milk 
only  in  having  a  lower  protein  and  fat  content,  and  a  slightly  higher 
carbohydrate  content. 

If,  therefore,  the  simple  test  for  gas  bacilli  in  the  stools  is  posi- 
tive, I  believe  it  is  best  to  begin  feeding  with  lactic  acid  milk.  This 
may  be  continued  until  it  fails  to  produce  either  a  negative  gas  bacil- 
lus test,  or  an  improvement  in  the  symptoms  after  a  few  days.  When 
ripened  milk  fails,  or  when  the  gas  bacillus  test  is  negative,  the  case 
should  be  treated  as  dysentery. 

In  beginning  artificial  feeding  in  infection  with  the  dysentery 
bacillus,  or  with  other  organisms  of  the  same  class,  the  food  should 
be  weak  at  first.  To  an  infant,  the  first  formula  given  after  the 
twenty-four  hours  of  water  diet  should  be — 

Fat,  I %— Lactose,  5%  — Protein,  .50%. 

The  food  should  be  gradually  strengthened  according  to  the  prin- 
ciples laid  down  in  the  division  on  feeding.  ■  If  ordinary  cow's  milk 
modification  does  not  seem  to  give  favorable  progress,  albumin  milk 
may  be  tried.  To  an  older  child,  dilute  boiled  milk  may  be  given, 
and  the  strength  of  the  mixture  is  to  be  gradually  increased.  Extra 
sugar  may  be  added.  Later  whey,  and  albumin  water  may  be  added 
to  the  diet,  and  still  later,  the  cereals. 

Routine  Treatment. — Irrigation  of  the  colon  is  a  very  useful 


Infectious  Diarrhea  479 

procedure  in  infectious  diarrhea,  and  should  be  part  of  the  routine 
treatment  in  every  case,  unless  it  appears  seriously  to  distress  or 
disturb  the  patient.  The  object  of  the  irrigation  is  to  remove  from 
the  wall  of  the  colon  as  much  as  possible  of  the  adherent  mucus, 
and  thus  to  favor  the  elimination  of  bacteria,  toxic  products,  and 
the  products  of  the  inflammation  of  the  tissues.  The  object  is  not 
to  promote  healing,  nor  to  kill  the  bacteria,  as  neither  astringent 
nor  antiseptic  solutions  can  be  used  in  a  strength  sufficient  to  pro- 
duce appreciable  effects.  Physiological  salt  solution  is  the  best  for 
irrigation  in  the  acute  stage.  It  should  be  given  once  or  twice 
daily,  but  not  oftener  than  twice.  The  technique  of  colon  irriga- 
tion has  been  described  in  Division  II.  When  the  case  tends  to 
become  prolonged  or  chronic,  with  the  continued  presence  of  blood 
and  pus  in  the  stools  after  the  fever  and  toxic  symptoms  have  dis- 
appeared, healing  injections  may  be  tried.  A  solution  of  silver 
nitrate  is  best  for  this  purpose.  Silver  nitrate  injections  should  be 
preceded  by  an  irrigation  of  the  colon,  given  in  the  ordinary  manner, 
except  that  sterile  water  should  be  used  instead  of  normal  salt  solu- 
tion, because  sodium  chloride  forms  an  insoluble  salt  with  silver 
nitrate.  After  the  irrigation  a  2%  solution  of  silver  nitrate  should 
be  injected  in  a  quantity  varying  from  one-half  a  pint  to  a  pint, 
according  to  the  age  of  the  baby.  After  the  injection  the  tube 
should  be  withdrawn,  and  the  patient  left  to  expel  the  solution  at 
leisure.  These  injections  may  be  repeated  daily,  or  every  second 
day.  If  they  cause  discomfort  the  silver  nitrate  may  be  washed 
out  with. normal  salt  solution,  and  the  next  injection  should  contain' 
silver  nitrate  in  weaker  solution.  The  stools  passed  immediately 
after  a  silver  nitrate  injection  may  contain  more  blood,  pus,  and 
necrotic  material  than  usual.  There  is,  however,  considerable  evi- 
dence that  these  injections  improve  the  character  of  the  later  stools, 
and  hasten  the  healing  processes.  The  benefits  to  be  expected  from 
either  colon  irrigations  or  silver  nitrate  injections  are  not  great 
enough  to  warrant  their  use  when  they  are  seriously  depressing 
or  disturbing. 

The  only  drug  of  possible  local  value  in  infectious  diarrhea  is  one 
of  the  salts  of  bismuth.  The  theoretical  action  of  bismuth  is  that 
it  forms  a  protective  and  soothing  coat  on  the  inflamed  mucous  mem- 
brane. My  own  experience  has  never  been  able  to  convince  me  that 
bismuth  does  any  real  good,  in  the  acute  stage  at  least.  In  the 
chronic  stage  some  cases  have  appeared  to  do  better  when  bismuth 
has  been  used.  The  subcarbonate  of  bismuth,  or  the  milk  of  bis- 
muth are  better  preparations  than  the  subnitrate,  on  account  of  the 
possible  danger  of  nitrate  poisoning  from  the  latter.  The  dose  should 
be  five  to  ten  grains  every  two  hours,  or  in  every  feeding. 

The   various   so-called   intestinal   antiseptics,    such   as   salol,    and 


480  Diseases  of  the  Gastro-Enteric  Tract 

similar  drugs,  are  of  no  value  in  infectious  diarrhea.  They  cannot 
be  given  in  doses  large  enough  to  injure  bacteria  without  greater 
injury  to  the  patient. 

If  it  is  impossible  to  induce  the  baby  to  take  a  sufficient  amount 
of  water,  or  if  water  or  food  given  through  a  tube  is  vomited,  fluid 
must  be  supplied  in  some  other  way.  Normal  salt  solution  may 
be  given  through  the  bowel  by  means  of  seepage,  and  even  when 
there  are  frequent  intestinal  discharges,  considerable  fluid  may  be 
absorbed.  If  sufficient  fluid  is  not  absorbed  when  given  by  rectum, 
salt  solution  may  be  given  subcutaneously.  In  very  severe  cases, 
fluid  may  be  given  intravenously. 

The  value  of  alcohol  in  infectious  diarrhea  is  a  matter  about 
which  opinions  differ.  The  preponderance  of  modern  opinion  denies 
to  alcohol  any  stimulant  value  in  the  treatment  of  disease.  In 
infants  and  children,  however,  who  are  suffering  from  prolonged 
infections  accompanied  by  nutritive  disturbance,  I  believe  alcohol 
to  be  of  value  as  an  easily  utihzable  source  of  energy.  I  beheve 
it  should  be  given  in  infectious  diarrhea,  to  an  infant,  in  doses  of 
lo  to  20  drops  of  whiskey  diluted  with  water,  and  to  older  children 
in  somewhat  larger  doses  proportioned  to  the  age  of  the  child. 

Treatment  oe  Special  Symptoms. — The  special  symptoms  re- 
quiring treatment  in  infectious  diarrhea  are  in  the  order  of  frequency 
of  occurrence,  pain  and  tenesmus,  marked  prostration,  collapse,  toxic 
nervous  irritation,  excessive  vomiting,  and  hyperpyrexia. 

When  abdominal  pain  and  tenesmus  are  present,  hot  stupes  or 
compresses  should  be  appHed  to  the  abdomen.  Injections  of  starch 
solution  may  be  tried  in  the  effort  to  relieve  tenesmus.  The  solu- 
tion for  injections  should  be  made  by  adding  two  teaspoonfuls  of 
starch  and  five  drops  of  tincture  of  opium  to  two  ounces  of  water. 
They  are  often  so  rapidly  expefled,  that  they  cannot  be  of  much 
benefit.  The  only  eft"ective  method  of  controlling  pain  and  tenesmus 
is  by  the  use  of  opium.  It  is  best  given  in  the  form  of  paregoric, 
'in  small  doses  proportioned  to  the  age  of  the  child.  From  five  to 
twenty  drops  may  be  given  to  infants,  repeated  often  enough  to 
relieve  the  pain  and  tenesmus,  and  to  check  excessive  peristalsis. 

For  marked  prostration,  stimulation  is  required.  Except  in  acute 
emergencies,  strychnin  is  the  best  stimulant,  given  in  doses  of  from 
i/iooo  to  1/200  of  a  grain.  In  place  of  strychnin,  caffein-sodium 
benzoate  may  be  used  in  doses  of  from  1/8  to  1/2  of  a  grain. 

For  coflapse  the  best  stimulant  is  fluid.  In  infants  it  is  best  given 
intravenously,  into  the  longitucUnal  sinus.  Normal  salt  solution  may 
be  used.  I  believe  that  marked  prostration  and  collapse  in  many 
cases  are  due  to  failure  to  absorb  enough  energy-producing  food. 
Infants  in  coflapse  need  fuel  as  well  as  water  and  alkali.  I  have 
recently   tried   giving   dextrose   intravenously   in   cases   of   this   kind. 


Infectious  Diarrhea  481 

Four  ounces  of  a  5%  solution  of  pure  dextrose  may  thus  be  given. 
In  some  cases  some  of  the  dextrose  is  excreted  in  the  urine,  but  in 
my  experience  part  of  it  is  always  actually  used  for  energy  produc- 
tion, and  in  some  cases,  it  has  all  been  used,  none  having  been 
excreted  in  the  urine.  I  have  never  seen  either  the  mythical  "sugar 
fever"  or  toxic  symptoms  follow  dextrose  injections  provided  that 
pure  dextrose  is  used.  Other  stimulants  which  may  be  used  in  col- 
lapse are  adrenalin,  in  doses  of  one  to  five  minims  intravenously, 
caffein-sodium  benzoate  or  salicylate  in  doses  of  1/8  to  1/2  a  grain 
subcutaneously,  and  camphor  in  oil  in  doses  of  one  to  two  grains 
intravenously. 

For  the  toxic  nervous  symptoms,  such  as  restlessness  or  signs  of 
meningeal  irritation,  sodium  bromide  is  the  best  drug.  It  is  best 
given  by  mouth  in  doses  of  five  grains,  repeated  in  two  hours  as 
often  as  is  necessary  to  control  the  symptoms.  If  the  fontanelle 
is  bulging,  lumbar  puncture  will  often  give  relief.  Ice  bags  to  the 
head  should  not  be  used,  unless  there  is  a  high  fever,  and  then 
cautiously. 

For  excessive  vomiting,  the  stomach  should  be  washed  out  with 
a  solution  of  sodium  bicarbonate,  one  teaspoonful  to  a  pint  of  water. 
This  may  be  repeated  daily.  Little  else  can  be  done  for  this  symp- 
tom, as  nutrient  enemata  will  not  be  retained. 

For  hyperpyrexia,  hydrotherapy  is  greatly  to  be  preferred  to  any 
form  of  medication.  The  coal-tar  products  are  not  advisable  in 
infants  and  young  children  on  account  of  their  depressing  effect. 
Sponge  baths  of  water  and  alcohol  in  equal  parts  at  about  90°  F.  are 
usually  the  best  measure  that  can  be  used  to  reduce  the  temperature. 
Hyperpyrexia  is  a  rare  symptom  in  infectious  diarrhea. 

SUMMARY  OF  THE  DISTURBANCES  OF  DIGESTION 
AND  INFECTIOUS  DIARRHEA 

The  disturbances  of  digestion  and  infectious  diarrhea  all  belong  to 
the  same  group,  in-so-far  as  symptoms,  diagnosis,  and  treatment  are 
concerned.  A  summary  of  the  principal  features  of  this  group  of 
diseases,  which  may  prove  useful  to  the  student,  is  given  in  table  44 : 

One  of  the  difficulties  in  the  diagnosis  and  treatment  of  this  group 
of  diseases  is  the  frequent  similarity  of  the  symptoms  seen  in  condi- 
tions which  differ  widely  in  etiology.  Our  treatment,  however,  must 
be  specifically  fitted  to  the  cause  of  the  condition,  and  it  is  for  this 
reason  that  these  diseases  are  classified  upon  an  etiologic  rather 
than  upon  a  symptomatic  basis.  Nevertheless,  these  conditions  pre- 
sent themselves  in  the  form  of  rather  definite  symptom-complexes. 
It  is  essential  for  the  physician  to  know  just  what  the  etiological 
conditions  are  which  can  produce  the  symptom-complex  with  which 

31 


482 


Diseases  or  the  Gastro-Enteric  Tract 


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Infectious  Diarrhea  483 

he  is  confronted.  A  table,  therefore,  showing  the  relation  of  the 
most  prominent  symptom  which  presents  itself  to  the  etiologic  classi- 
fication of  these  diseases,  may  prove  useful  for  reference.  Symp- 
tomatically,  the  conditions  which  present  themselves  may  be  di\^ded 
into  acute  and  chronic. 

There  are  four  rather  definite  clinical  pictures  encountered  in 
acute  cases.  In  the  first,  vomiting  is  the  only  symptom,  the  physi- 
cian being  called  upon  to  treat  an  acute  attack  of  vomiting.  In  the 
other  three  clinical  pictures  the  principal  symptom  is  acute  diarrhea, 
the  t}^es  differing  according  to  the  character  of  the  stools.  The 
second  clinical  t}'pe  is  characterized  by  stools  of  undigested  appear- 
ance, containing  curds  and  undigested  masses.  The  third  type  is 
characterized  by  watery,  green  or  brown  stools.  The  fourth  type  is 
characterized  by  stools  which  contain  blood  and  mucus.  In  the 
two  last  types  toxic  symptoms  may  be  present.  The  relation  of 
these  four  clinical  types  to  the  etiological  classification  of  this  group 
of  diseases  is  shown  in  table  45 : 

Table  45 

Symptom-complex  in  Acute  Cases  a7id  Causes 

Vomiting  only  symptom Indigestion  from  excess  of  food 

Diarrhea,  imdigested  stools Indigestion  from  overfeeding 

Diarrhea,  watery,  green,  or  brown  stools Indigestion  with  fermentation 

Diarrhea,  blood  and  mucus  in  stools Infectious  diarrhea 

The  cHnical  t}^es  which  present  themselves  in  chronic  cases  are 
also  rather  definite,  but  have  a  much  less  definite  relation  between 
the  symptoms  and  the  disease  which  causes  them.  In  the  first 
type,  vomiting  is  the  only  symptom.  The  second  type,  frequently 
encountered,  shows  no  symptom  other  than  loss  of  weight,  the  stools 
being  macroscopically  of  approximately  normal  appearance.  In  the 
third  type,  the  stools  are  hard,  dry,  and  of  a  whitish  or  yellowish- 
white  color.  In  the  fourth  type  the  stools  are  of  approximately 
normal  consistency,  but  are  green  in  color.  In  the  fifth  type  the 
stools  are  rather  looser  than  the  normal,  but  not  so  loose  as  in  acute 
diarrhea,  and  are  of  a  green  color.  In  the  sixth  type  the  stools  are 
undigested,  containing  curds,  or  undigested  masses.  The  relation 
of  these   cfinical  types    to    the    etiological   classification    is  shown 

in  table  46: 

Table  46 

Symptom-complex  in  Chronic  Cases  and  Causes 

[Indigestion  from  excess  of  food 

Vomiting  only  symptom j  Indigestion  from  excess  of  fat 

[indigestion  from  excess  of  protein 

Loss  of  weight.     Stools  macroscopically  normal. /Underfeeding 

\Indigestion  from  excess  of  fat 


484  Diseases  of  the  Gastro-Enteric  Tract 

Table  46 — Continued 
Hard,  dry,  whitish  or  yellowish  stools Indigestion  from  excess  of  fat 

Green  stools,  normal  consistency. f Indigestion  from  excess  of  food 

\lndigestion  from  excess  of  carbohydrate 

Loose,  green  stools f Indigestion  from  excess  of  carbohydrate 

\lndigestion  from  excess  of  fat 

[Indigestion  from  excess  of  food 

Undigested,  curdy  stools ^Indigestion  from  excess  of  fat 

[Indigestion  from  excess  of  protein 

PROBLEMS  AND  RESEARCH  IN  DISEASES  OF  THE 
DIGESTIVE  TRACT 

This  field  in  pediatrics  is  of  the  highest  importance  and  is  the  sub- 
ject of  the  most  bitter  controversy.  The  lack  of  distinctive  path- 
ology, cases  of  varied  symptomatology  showing  at  autopsy  prac- 
tically the  same  findings,  makes  a,  classification  along  these  Hnes 
most  difficult.  For  the  same  reason  the  etiological  factors  are  not 
clear.  Chemical  and  bacteriological  agents  are  both  concerned  and 
the  question  of  the  importance  of  the  part  that  each  plays  is,  un- 
fortunately, decidedly  an  unsettled  one. 

The  work  of  the  Rockefeller  Institute  and  later  work  on  the  Boston 
Floating  Hospital  by  Ten  Broek  seems  to  have  definitely  established 
the  fact  that  there  is  a  real  dysentery  among  other  alimentary  path- 
ological conditions.  In  nearly  every  case  in  which  pus  and  especially 
blood  is  present  in  the  stools,  the  organism  of  dysentery  can  be  iso- 
lated from  the  movements  and  agglutination  tests  on  the  blood  will 
show  a  positive  reaction  to  the  organism  later  on  in  the  course  of 
the  disease.  (From  a  paper  by  Ten  Broek  and  Norbury,  as  yet 
unpubHshed.)  This  applies  only  to  the  condition  known  as  infectious 
diarrhea  in  the  vicinity  of  Boston.  It  may  be  found  to  apply  to  other 
locaHties  also,  but  at  present,  no  sufficiently  thorough  work  has  been 
done.  Although  it  is  probable  that  other  organisms,  the  streptococcus, 
colon  bacillus,  etc.,  may  play  a  part,  it  is  not  probable  that  it  is  an 
extensive  one,  as  an  excitant  of  dysenteric  conditions. 

It  is  the  symptom-complex,  called  by  some  authors  Fermentative 
Indigestion  and  by  others  Intoxication,  that  is  the  cause  of  so  m.uch 
difference  in  pediatric  thought  along  these  lines.  On  the  one  hand 
are  found  the  supporters  of  the  bacterial  origin  of  this  condition, 
on  the  other  hand  are  those  who  consider  the  injury  primarily  a 
chemical  one,  soon  becoming  systemic.  The  one  group  holds  that 
the  bacteria  already  present  may  increase  under  certain  conditions, 
or  that  masses  of  bacteria  may  be  introduced  with  the  food,  and 
that  their  products  are  toxic  and  irritating,  causing  the  general  pros- 
tration and  the  diarrhea.  The  other  group  believes  that  a  chemical 
injury  may  occur  to  the  epithehal  cells  of  the  wall  of  the  intestine 


Cholera  Infantum  485 

and  by  raising  their  permeability  to  toxic  chemical  products,  allow 
these  bodies  to  enter  the  blood  stream.  In  this  case  the  injury  would 
be  a  "food  injury"  and  if  bacteria  or  other  products  were  involved, 
it  would  be  a  secondary  affair.  It  is  true  that  Steinitz  has  found  that 
h>'perpermeability  exists  for  certain  enzymes  (diastase  and  maltase), 
and  that  Lust  has  noticed  the  same  reaction  for  protein  bodies,  in 
these  cases.  ]Moro  has  shown  in  animals  that  an  endogenous  infec- 
tion of  the  small  intestine  does  not  cause  hyperpermeability  of  its 
walls  to  protein. 

In  intoxication  many  organisms  which  are  usually  present  are 
found  in  increased  numbers.  It  may  well  be  that  their  virulence 
is  increased  by  the  varied  culture  media  off'ered  to  theiji;  Passini 
has  been  able  to  show,  in  vitro,  that  the  "gas  bacillus"  may,  under 
certain  food  conditions,  manufacture  a  powerful  toxin.  There  have 
also  been  attempts  to  show  that  the  colon  bacillus  is  found  in  in- 
creased numbers,  so  as  to  cause  a  characteristic  appearance  in  stained 
cover  glass  preparations  from  the  stools  in  these  cases. 

Both  theories  are  suh  judice.  It  seems  reasonable  to  believe  in 
the  possibility  that  both  may  be  responsible  for  this  very  obscure 
condition,  each  under  different  circumstances.  It  seems  probable 
that  more  than  one  condition  is  described  under  the  head  of  A  limen- 
tary  Intoxication. 

With  regard  to  the  "gas  bacillus"  one  may  say  that  more  work 
must  be  done  before  it  can  be  estabHshed  as  an  etiological  factor. 
Its  increase  under  certain  conditions  may  be  purely  secondary,  as 
increase  in  the  bacterial  flora  is  a  common  occurrence  when  the 
function  of  the  intestine  is  impaired.  It  is  of  such  common  occur- 
rence in  the  intestinal  tract  as  to  justify  its  being  considered  a  fairly 
normal  inhabitant  of  those  parts. 

CHOLERA  INFANTUM 

This  name  is  appHed  to  a  very  definite  symptom-complex,  the 
etiology  of  which  is  entirely  unknown.  It  is  possible  that  the  disease 
may  be  caused  by  some  particular  type  of  fermentation  process  in 
the  intestinal  contents,  or  even  that  it  may  be  due  to  some  pecu- 
liar form  of  food  poisoning.  Nevertheless,  the  definiteness  of  the 
clinical  picture,  and  the  character  of  the  symptoms  strongly  suggest 
that  it  is  an  acute  specific  infection.  The  disease  is  a  very  rare  one. 
In  Boston,  I  have  only  seen  one  or  two  cases  which  fulfilled  the 
description  of  the  condition.  The  term  cholera  infantum  is,  however, 
very  generally  wrongly  applied  to  severe  cases  of  acute  indigestion 
with  fermentation. 

ETIOLOGY. — If  there  is  a  specific  organism  in  cholera  infantum, 
it  has  not  been  found.     The   disease   occurs   only  in   the   first   two 


486  Diseases  of  the  Gastro-Enteric  Tract 

years  of  life,  and  in  its  development  is  probably  closely  associated 
with  the  food,  for  it  has  been  noticed  that  infants  who  are  fed  ex- 
clusively on  breast-milk,  are  not  liable  to  be  attacked  by  it.  It 
is  also  significant  that  the  disease  occurs  only  in  hot  weather. 

PATHOLOGICAL  ANATOMY.— The  pathology  of  cholera  in- 
fantum has  not  yet  been  satisfactorily  determined,  but  it  seems  to 
be  a  non-inflammatory  disturbance  of  the  whole  gastro-enteric  tract, 
without  any  gross  lesion  beyond  a  desquamative  catarrh,  and  some- 
times hyperemia  of  the  mucous  membrane. 

SYMPTOMS." — The  onset  of  cholera  infantum  may  be  sudden, 
but,  as  a  rule,  it  is  preceded  by  some  form  of  gastro-enteric  disturb- 
ance, which,  by  causing  an  irritation  of  the  mucous  membrane,  renders 
the  infant  vulnerable.  When,  however,  the  disease  has  once  gained 
a  foothold,  the  development  of  the  symptoms  is  very  rapid. 

After  a  variable  but  generally  short  period  of  restlessness  and 
apparent  abdominal  discomfort,  the  infant  begins  to  vomit.  The 
vomiting  is  either  accompanied  or  quickly  followed  by  profuse  diar- 
rhea. After  the  stomach  and  intestine  have  been  emptied  of  the 
food  which  may  happen  to  be  in  them  at  the  time  of  the  onset,  the 
vomitus  and  the  diarrheal  discharges  are  chiefly  serous;  and  it  is 
this  watery  consistency  of  the  discharges  which  especially  charac- 
terizes the  disease.  As  a  rule,  the  discharges  are  odorless,  and  con- 
sist of  serum  mixed  with  epithelial  cells  and  many  bacteria.  Although 
the  disease  is  more  likely  to  attack  weak  and  debilitated  infants,  yet 
it  occasionally  attacks  those  who  are  healthy  and  robust.  It  may 
run  its  course  to  a  fatal  issue  in  from  twenty-four  to  forty-eight 
hours.  The  extremities  soon  become  cold,  the  skin  is  palHd  or  even 
cyanotic,  and  the  face  pinched.  The  abdomen  may  at  first  be  a  little 
distended,  but  is  soft,  and  soon  becomes  retracted.  The  pulse  is  rapid 
and  difficult  to  count.  The  respirations  are  somewhat  rapid  and 
superficial.  The  temperature  of  the  entire  surface  of  the  body  is 
low,  but  the  deep  rectal  temperature  is  high  (103°,  104°,  or  105°  F.). 
The  thirst  is  great  and  is  a  very  prominent  symptom.  The  fonta- 
nelle  very  soon  becomes  depressed.  The  urine  is  very  scanty  and 
sometimes  suppressed.  It  is  concentrated,  highly  acid,  almost  always 
contains  albumin,  and  often  casts  and  blood.  Nervous  symptoms, 
such  as  twitching  of  the  arms  and  great  restlessness  are  present. 
Rapid  emaciation  takes  place,  and  all  the  symptoms  increase  in 
severity.  At  first  the  infant  whimpers,  but  soon  it  becomes  Hstless, 
falls  into  a  stupor,  or  may  have  convulsions.  The  infant  may  die 
in  this  stage,  which  closely  resembles  the  algid  stage  of  cholera 
Asiatica.  The  disease  appears  to  be  self-limited,  and  if  the  infant 
survives  the  first  two  or  three  days  a  crisis  comes,  the  skin  becomes 
less  cool  and  of  a  better  color,  the  vomiting  and  diarrhea  becomes  less 


Cholera  Infantum  487 

frequent,  and  finally  it  is  left  with  a  slight  amount  of  simple  diar- 
rhea and  occasional  vomiting.  These  symptoms  may  become  chronic, 
in  which  case  the  infant  finally  dies  of  exhaustion  or  from  an  attack 
of  one  of  the  other  gastro-enteric  diseases,  to  which  it  is  left  very 
susceptible. 

DIAGNOSIS. — The  diagnosis  of  cholera  infantum  is  not  difficult 
if  the  characteristic  symptoms  are  borne  in  mind;  these  are  rapid 
onset,  constant  vomiting,  frequent  serous  discharges,  intense  thirst, 
high  rectal  temperature,  low  surface  temperature,  collapse,  depressed 
fontanelle,  sudden  loss  of  weight,  and  distressed,  restless  expression, 
suggesting  speedy  death,  all  developing  in  from  twenty-four  to  forty- 
eight  hours.  It  is  distinguished  from  fermental  diarrhea  by  the 
serous  nature  of  the  intestinal  discharges,  and  by  the  constant  high 
rectal  temperature. 

PROGNOSIS. — The  prognosis  is  bad.  The  more  violent  the 
attack,  the  higher  the  temperature,  the  less  the  vitality,  and  the 
warmer  the  weather,  the  worse  is  the  prognosis.  When  the  infant 
has  survived  the  very  acute  symptoms  which  appear  in  the  first  two 
or  three  days,  the  prognosis  is  more  favorable. 

TREATMENT. — Cholera  infantum  is  so  formidable  in  its  attack 
that  it  must  be  treated  most  energetically  if  we  hope  to  succeed  in 
saving  the  infant's  life.  The  indications  for  treatment  are  (i)  to 
assist  the  effort  which  nature  is  making  to  free  the  stomach  and 
intestine  from  the  poison  which  is  in  them;  (2)  to  restore  the  surface 
circulation,  which  is  so  seriously  interfered  with;  (3)  to  supply  water 
to  the  tissues,  which  are  being  drained  to  so  grave  an  extent;  and 
(4)  to  support  the  strength  until  the  disease  has  run  its  course. 

The  poison  seems  to  act  with  especial  virulence  on  those  portions 
of  the  economy  where  it  is  most  concentrated, — namely,  the  stomach 
and  the  intestine.  We  therefore  have  at  first  extreme  irritation  of 
these  parts,  which  causes  increased  peristalsis,  and  later  vasomotor 
paralysis,  with  great  transudation  of  serum.  This  condition  of  the 
gastro-enteric  tract  is  to  be  especially  borne  in  mind  during  the 
whole  course  of  our  treatment. 

In  this  disease  we  should  not  attempt  to  use  any  remedy  which 
works  slowly.  The  condition  of  the  mucous  membrane  is  in  all 
probability  such  that  absorption  of  drugs  does  not  take  place  readily. 
The  administration  of  drugs  is,  therefore,  contra-indicated,  for  they 
may  later,  when  absorption  is  being  restored,  prove  fatal  by  their 
cumulative  action.  During  the  acute  stage  of  the  disease  the  diges- 
tive functions  fail  to  act,  and  therefore  food  of  any  kind  will  be  only 
an  additional  source  of  irritation. 

Early  in  the  attack,  and  when  the  vomiting  has  not  caused  much 
prostration,  the  stomach  should  be  thoroughly  washed  out  with  warm 


Diseases  of  the  Gastro-Enteric  Tract 

water  and  the  intestine  should  be  irrigated.  If  the  rectal  tempera- 
ture is  very  high,  cold  water  may  be  used  for  irrigation.  When  the 
vomiting  has  continued  for  some  time  and  there  is  prostration  with 
great  thirst,  the  infant  should  be  allowed  to  suck  sterilized,  ice-cold 
water  from  the  bottle.     At  first  nothing  else  should  be  given  by  mouth. 

The  infant  should  be  placed  at  once  in  a  warm  pack.  This  should 
be  done  by  wrapping  it  to  the  chin  in  sheets  wrung  out  of  water  at 
least  as  hot  as  38°  C.  (100.4°  F.).  It  should  then  be  enveloped  in 
a  hot  blanket.  This  procedure  should  be  repeated  as  often  as  the 
infant  shows  signs  of  collapse  or  much  cyanosis  and  coldness  of  the 
skin.  This  is  the  best  method  that  we  know  of  to  restore  the  surface 
circulation. 

While  the  infant  is  in  the  hot  pack,  water  can  be  given  freely  by 
the  mouth  and,  if  necessary,  small  and  frequently  repeated  doses  of 
stimulants,  unless  they  appear  to  excite  vomiting,  in  which  case  they 
should  be  given  hypodermically. 

If  the  vomiting  and  diarrhea  continue  to  be  excessive  after  this 
treatment,  small  doses  of  morphine,  0.0006  gramme  (i/ioo  grain), 
and  atropin,  0.00008  gramme  (1/800  grain),  for  an  infant  a  year 
old,  can  be  tried  hypodermically.  The  effect  should  be  carefully 
watched,  and  the  dose  repeated  if  necessary. 

The  feeding  and  stimulation  of  these  cases  should  be  carried  out 
as  described  for  severe  cases  of  infectious  diarrhea.  The  giving  of 
fluid  subcutarieously  or  intravenously  is  of  special  importance. 

GASTRITIS 

Gastric  infection  is  extremely  rare,  and  in  frequency  of  occurrence 
presents  a  marked  contrast  with  that  of  intestinal  infection. 

ETIOLOGY.— Improper  feeding,  with  its  resulting  gastric  indi- 
gestion, is  the  predisposing  cause,  infection  probably  resulting  from 
increased  vulnerability  of  the  gastric  mucus  membrane.  The  nature 
of  the  infection  is  variable,  but,  with  the  exception  of  its  occurrence 
in  connection  with  such  diseases  as  tuberculosis  and  diphtheria,  the 
streptococcus  is  probably  the  most  frequent  organism  present. 

PATHOLOGICAL  ANATOMY.— The  lesions  found  in  infectious 
gastritis  may  be  divided  into  (a)  catarrhal,  (b)  ulcerative  and  (c) 
pseudomembranous  gastritis. 

Catarrhal  gastritis  shows  hyperemia  of  the  mucous  membrane, 
hypersecretion  of  mucus,  small  punctate  hemorrhages  and  slight 
thickening  of  the  mucous  coat. 

The  undigested  food  remains  longer  than  normal  in  the  stomach 
and  is  mixed  with  an  excess  of  mucus. 

Microscopically  the  changes  are  confined  mainly  to  the  mucosa 
and  consist  of  degeneration,  infiltration  in  places  with  round  cells 


Gastritis  489 

and  at  times  loss  of  surface  epithelium.  Rarely,  in  chronic  cases, 
there  is  more  marked  infiltration  and  an  increase  of  the  connective 
tissue. 

Ulcerative  gastritis  is  extremely  rare.  The  ulcers  are  usually  follic- 
ular, numerous,  vary  from  mere  dots  to  1/4  inch  in  diameter,  and 
usually  involve  only  the  mucosa. 

Pseudomembranous  gastritis  is  still  more  rare.  In  this  condition 
there  is  a  grayish  or  greenish  adherent  false  membrane,  consisting 
microscopically  of  fibrin,  granular  matter,  epitheHal  cells,  and  detritus. 

There  is  round-celled  infiltration  of  the  mucosa,  submucosa,  and 
sometimes  even  of  the  muscular  coat.  This  form  is  usually  accom- 
panied by  ulcerative  gastritis. 

SYMPTOMS.— Of  the  different  forms  of  gastritis,  the  catarrhal 
is  very  much  the  most  common.  There  are  no  pecuHar  symptoms 
by  which  the  ulcerative  and  pseudomembranous  varieties  can  be 
recognized  \dth  any  certainty. 

Acute  Gastritis. — The  symptoms  of  acute  catarrhal  gastritis 
resemble  at  the  onset  those  of  acute  indigestion.  There  is  nausea, 
vomiting,  thirst,  loss  of  appetite,  and  usually  some  prostration. 
Fever  is  always  present,  whereas  it  is  usually  absent  in  indigestion. 
Abdominal  tenderness  is  present.  The  continuance  of  the  symptoms, 
particularly  those  of  fever,  vomiting,  pain,  and  tenderness,  is  the 
basis  for  the  diagnosis  of  acute  gastritis.  The  temperature  is  usually 
moderate,  37.7°-38.8°  C.  (ioo°-io2°  F.)  after  the  onset. 

There  may  be  constitutional  symptoms  at  the  onset.  There  is 
usually  frothy  mucus  in  the  vomitus,  which  is  sometimes  streaked 
with  blood. 

DIAGNOSIS.— Gastritis  is  so  rare  a  disease  in  early  Hfe,  that 
the  diagnosis  is  not  often  made.  It  is  much  commoner  for  cases 
of  indigestion  to  be  WTongly  diagnosed  as  gastritis  than  for  cases 
of  gastritis  to  be  overlooked.  The  symptoms  are  much  like  those 
of  indigestion,  with  vomiting  as  the  principal  manifestation.  Fever 
and  tenderness  over  the  epigastrium,  which  are  characteristic  symp- 
toms of  gastritis,  are  practically  never  seen  in  indigestion.  Those 
forms  of  indigestion  which  have  fever  are  characterized  usually  by 
diarrhea  or  abnormal  movements  rather  than  by  vomiting,  and  diar- 
rhea is  usually  not  present  in  gastritis.  The  diagnosis  depends  on 
the  coexistence  of  vomiting,  continued  fever,  epigastric  pain  and 
tenderness. 

PROGNOSIS.— Attacks  of  acute  catarrhal  gastritis,  even  when 
properly  treated,  are  apt  to  last  for  from  three  to  seven  days.  When 
not  properly  treated  they  may  be  prolonged  or  chronic  gastritis 
may  develop.     When  properly  treated  the  prognosis  is  good. 


490  Diseases  of  the  Gastro-Enteric  Tract 

TREATMENT. — The  treatment  of  acute  gastritis  is  much  Hke 
that  of  acute  indigestion  with  vomiting.  The  initial  administration 
of  calomel  should,  however,  be  omitted.  It  is  necessary  also  that 
food  be  withheld  for  a  longer  period,  and  in  severe  cases  nothing 
should  be  given  by  mouth  for  several  days.  Whenever  it  is  neces- 
sary to  give  no  food  by  mouth  for  more  than  twenty-four  hours, 
rectal  feeding  should  be  instituted..  The  patent  may  be  given  from 
four  to  six  ounces  of  peptonized  milk,  or  of  a  6%  dextrose  solution 
every  four  hours,  by  rectum.  A  little  salt  solution  may  also  be 
given  by  rectum  between  the  nutrient  enemata.  If  the  child  is 
very  thirsty,  iced  soda  water  in  very  small  doses  may  be  given  by 
mouth,  unless  it  appears  to  increase  the  vomiting. 

The  time  when  feeding  by  mouth  should  be  resumed,  must  depend 
upon  the  circumstances  of  the  individual  case.  In  general,  food  by 
mouth  should  not  be  given  until  a  marked  improvement  has  appeared 
in  the  symptoms.  Albumin  water  or  whey  are  good  preparations 
for  beginning  feeding.  Later,  a  very  weak  milk  modification  con- 
taining lime  water,  or  sodium  bicarbonate,  should  be  given.  The 
strength  of  the  food  is  gradually  increased  according  to  the  digestive 
requirements  of  the  individual.  When  serious  symptoms,  such  as 
prostration  and  collapse  occur,  the  general  measures  which  are  used 
are  like  those  in  similar  conditions. 

PROCTITIS 

Proctitis  is  an  inflammation  of  the  rectum,  and  may  be  acute  or 
chronic.  It  is  usually  coincident  with  inflammation  of  the  colon, 
but  may  occur  alone  as  the  result  of  trauma  or  the  extension  of 
inflammatory  processes  around  the  anus. 

SYMPTOMS. — The  symptoms  are  essentially  pain,  traces  of 
blood  mixed  with  mucus,  and  tenesmus. 

DIAGNOSIS. — The  diagnosis  from  reflex  inflammatory  conditions 
is  made  by  direct  inspection. 

TREATMENT.— The  treatment  is  to  keep  the  child  in  bed,  to 
keep  the  feces  soft  with  laxatives,  to  cleanse  the  rectum,  and,  ac- 
cording to  the  especial  lesions,  use  astringents  or  soothing  injec- 
tions. Where  there  is  pain  or  tenesmus,  suppositories  of  opium  are 
indicated. 

APPENDICITIS 

Appendicitis  occurs  at  all  ages,  and  is  not  especially  a  disease  of 
early  life.  Only  the  pecuUarities  of  the  disease  as  seen  in  children 
will  be  described  here. 

ETIOLOGY. — Inflammation  of  the  vermiform  appendix  in  chil- 
dren is  most  frequent  between  the  ages  of  five  and  fifteen  years, 


Appendicitis  491 

and  is  not  of  uncommon  occurrence.  It  is  very  rare  under  two 
years.  Several  cases  have  been  reported  as  early  as  seven  weeks. 
Boys  are  more  often  attacked  than  girls,  in  about  the  same  propor- 
tion as  in  adults.  Little  is  known  as  to  the  predisposing  or  exciting 
causes  of  an  attack.  Foreign  bodies  are  infrequent,  despite  the 
general  opinion,  and  although  the  presence  in  the  appendix  of  fecal 
concretions,  often  resembling  seeds  and  stones  of  fruit,  is  very  com- 
mon, their  exact  relation  to  the  inflammation  is  not  clear.  Intes- 
tinal worms,  both  lumbricoid  and  the  oxyuris,  have  been  found  within 
the  appendix  and  presumably  have  been  the  inciting  cause.  Direct 
trauma,  as  from  a  blow  in  the  abdomen,  is  sometimes  a  definite 
exciting  cause.  The  prevailing  opinion  is  to  consider  the  process 
an  infectious  inflammation,  though  no  specific  organism  has  been 
shown  to  cause  it.  On  the  contrary,  cultures  of  the  colon  bacillus 
alone,  or  mixed  infections  of  the  colon  bacillus  associated  with  the 
streptococcus,  pneumococcus,  staphylococcus  albus  or  aureus,  the 
bacillus  aerogenes,  and  certain  undetermined  anaerobic  organisms  are 
found.  The  transformation  of  the  appendix  into  a  closed  tube  is  to 
be  considered  as  a  consequence  rather  than  a  cause  of  appendicitis. 

PATHOLOGICAL  ANATOMY.— The  pathological  "conditions  oc- 
curring in  the  course  of  an  appendicitis  are  exceedingly  varied,  and 
will  only  be  outlined.  In  the  early  stages  of  a  purely  appendicular 
lesion,  the  appendix  is  in  normal  position  and  may  show  only  slight 
swelling  and  congestion.  Usually  it  is  voluminous  from  extensive 
infiltration  of  its  walls,  very  turgescent,  and  often  shows  spots  of 
ecchymoses  with  intense  congestion  of  the  peritoneal  coat.  In  more 
advanced  stages  the  mucosa  is  soft  and  granular,  sometimes  gela- 
tinous, with  ecchymoses  and  ulcerations.  The  muscular  coats  are 
thickened  and  their  fibres  often  separated  by  minute  or  extensive 
accumulations  of  pus.  All  these  changes  may  develop  in  from 
twenty-four  to  thirty-six  hours  after  the  onset  of  symptoms.  Per- 
foration and  gangrene  of  the  appendix,  in  part  or  in  whole,  are  simply 
further  steps  in  the  inflammatory  process,  and  are  especially  likely 
to  occur  in  children. 

The  inflammation  is  rarely  confined  to  the  appendix,  but  by  ex- 
tension involves  the  peritoneal  coat  of  the  appendix  and  the  peri- 
toneum itself.  The  subsequent  course  is  very  variable.  The  pro- 
cess may  remain  local,  and  lead  to  a  peri-appendicular  inflammation, 
in  which  the  appendix,  cecum,  and  end  of  the  ileum  are  shut  oflf 
from  the  rest  of  the  peritoneal  cavity  by  adhesions,  with  or  without 
the  formation  of  pus;  or  the  infection  may  spread  directly  from  the 
appendix  to  the  general  peritoneal  cavity,  with  the  production  of 
general  septic  peritonitis.  The  location  of  the  pus  in  cases  of  abscess 
formation  depends  to  some  extent  upon  the  location  of  the  appendix, 


492  Diseases  of  the  Gastro-Enteric  Tract 

in  which  there  is  considerable  variation.  It  may  be  either  iliac, 
pre-rectal,  sub-umbiUcal,  retro-cecal,  or  lumbar  in  its  disposition. 

A  most  malignant  form  of  general  peritonitis  may  follow  a  simple 
parietal  appendicitis  without  perforation  or  gangrene  of  the  appendix, 
and  give  rise  to  a  clinical  picture  more  suggestive  of  septicemia 
than  of  peritonitis. 

A  simple  appendicitis,  sometimes  called  catarrhal,  may  produce 
so  much  thickening  of  the  walls  and  infiltration  of  the  submucosa 
with  leucocytes,  and  subsequent  formation  of  granulation  tissue,  as 
to  cause  an  obliteration  of  the  lumen  of  the  appendix.  If  the  lumen 
is  completely  obHterated,  it  may  render  the  patient  immune  to 
subsequent  attacks,  but  if  only  partial,  it  favors  the  collection  of 
pockets  of  pus  and  cyst  formation,  and  the  organ  is  then  a  constant 
source  of  danger. 

SYMPTOMS. — In  many  cases  the  symptoms  of  appendicitis  in 
children  are  like  those  of  appendicitis  in  adults,  presenting  the  familiar 
picture  of  abdominal  pain,  localized  tenderness,  muscular  rigidity, 
and  distention  with  vomiting  and  fever.  This  adult  type  is  most 
common  in  older  children,  and  presents  comparatively  Httle  diffi- 
culty in  diagnosis.  In  younger  children,  the  clinical  manifestations 
of  the  disease  are  often  very  atypical,  and  present  the  greatest  diffi- 
culties in  diagnosis.  The  younger  the  child,  the  more  irregular  is 
the  onset  and  course  likely  to  be,  and  the  greater  the  difficulty  in 
recognizing  the  nature  of  the  disease. 

The  atypical  features  of  the  disease  may  be  summarized  as  fol- 
lows: Pain,  while  usually  present,  is  often  indefinite  and  hard  to 
recognize.  It  often  appears  to  be  paroxysmal  in  character,  attacks 
of  crying  coming  at  more  or  less  regular  intervals.  It  is  often  not 
definitely  referred  to  the  right  ihac  region,  or  even  to  the  right  side, 
but  is  referred  at  different  times  to  various  parts  of  the  abdomen. 
In  infants  restlessness  and  irritabihty  may  be  the  only  sign  of  pain, 
or  there  may  be  frequent  attacks  of  cr5dng.  When  these  manifes- 
tations occur  in  paroxysms,  with  quiet  intervals,  it  is  particularly 
suspicious. 

Tenderness  on  abdominal  palpation  is  often  still  more  difficult  to 
recognize  than  pain.  Young  children  cannot  cooperate  with  the 
examining  physician  in  saying  when  palpation  hurts  them,  and  the 
examiner  must  judge  by  the  facial  expression  and  actions  of  the 
patient.  Young  children  often  resist  examination  strenuously,  or, 
if  nervous  and  sensitive,  shrink  from  the  slightest  touch.  Even  when 
they  are  old  enough  to  answer  questions,  their  repUes  may  be 
misleading.  When  evidences  of  pain  on  palpation  are  found,  the 
tenderness  often  cannot  be  localized.  When  localized  tenderness  is 
found,  it  is  often  not  situated  in  the  right  ihac  region,  but  high  up 


Appendicitis  493 

on  the  right  side,  near  the  Hver,  or  nearer  the  centre  of  the  abdomen. 
I  have  seen  cases  in  which  tenderness  appeared  to  be  entirely  absent. 

Muscular  rigidity  is  often  equally  difi&cult  to  determine.  In  young 
children  it  is  often  necessary  to  divert  the  attention  from  the  exami- 
nation, and  this  can  only  be  accomplished  by  the  exercise  of  tact 
and  patience.  When  the  physician  can  be  sure  that  real  invol- 
untary spasm  of  the  muscles  of  the  abdominal  wall  is  present,  it  is 
a  sign  of  great  importance.  Even  when  the  examination  is  satis- 
factory, muscular  rigidity  may  be  absent. 

Often  the  only  evidences  of  tenderness  and  muscular  rigidity  are 
a  disinclination  on  the  part  of  the  child  to  move  the  trunk  or  lower 
extremities,  or  signs  of  pain  when  the  patient  is  moved.  Sometimes 
the  right  thigh,  or  both  thighs,  are  held  rigidly  flexed. 

Abdominal  distention  may  be  present  or  absent.  When  present 
in  connection  with  other  symptoms,  it  is  an  aid  in  diagnosis.  Fever 
in  children  is  apt  to  be  higher  than  in  adults,  and  high  fever  in  con- 
nection with  any  abdominal  symptoms,  but  unaccompanied  by  diar- 
rhea, is  very  significant.  There  are  many  exceptions,  however. 
While  some  fever  is  almost  always  present,  the  temperature  may  be 
very  moderately  raised.  Constipation  is  usually  present,  but  may 
be  absent,  and  diarrhea  is  sometimes  seen.  There  is  usually  a  poly- 
morphonuclear leukocytosis,  the  white  count  being  about  20,000. 
Acetonuria  is  usually  present  early  in  the  disease. 

Of  all  the  symptoms  of  appendicitis  in  early  life,  vomiting  is  the 
most  common.  In  insidious  cases  the  symptom-complex  is  vomiting, 
fever,  and  paroxysmal  crying.  The  other  symptoms  and  signs  are 
confirmatory  when  present,  but  are  often  absent,  or  difficult  to 
recognize. 

Course  of  the  Disease. — When  the  clinical  picture  of  appen- 
dicitis in  children  resembles  that  seen  in  adults,  the  course  and  ter- 
mination of  the  disease  are  also  like  those  of  adults.  The  symptoms 
may  improve  after  a  few  days,  and  recovery  may  take  place,  to  be 
followed  by  another  attack  after  a  number  of  months.  In  other 
cases  the  symptoms  may  either  slowly  or  rapidly  increase  in  severity, 
with  continued  vomiting  and  fever,  rising  pulse  and  temperature, 
increasing  abdominal  distention  and  rigidity,  and  increasing  pros- 
tration. In  such  cases  death  occurs  as  a  result  of  general  perito- 
nitis in  from  four  to  eight  days. 

In  the  atypical  types,  so  common  in  younger  children,  the  course 
of  the  disease  is  much  more  irregular.  The  indefinite  clinical  picture 
may  persist  for  several  days.  Only  comparatively  slight  vomiting, 
moderate  fever,  and  indefinite  evidences  of  pain  may  be  present 
after  the  onset.  The  child  is  fretful,  wants  to  be  let  alone,  and  resists 
examination  so  that  definite  tenderness  cannot  be  made  out.  Pros- 
tration is  not  marked,  and  the  child  may  not  seem  very  ill.     Never- 


494  Diseases  of  the  Gastro-Enteric  Tract 

theless,  under  these  circumstances  gangrene  or  perforation  may 
occur  without  preliminary  warning.  The  child  now  begins  to  get 
worse,  either  gradually  or  rapidly,  and  begins  to  look  seriously  ill, 
while  the  pulse  rate  rises,  prostration  increases,  and  abdominal  dis- 
tention becomes  marked.  At  operation,  a  gangrenous  appendix  and 
general  peritonitis  may  be  found,  or  a  locaHzed  appendix  abscess. 

DIAGNOSIS. — ^Abdominal  tenderness  is  the  sign  of  greatest  diag- 
nostic significance  in  children,  when  it  can  be  obtained.  It  is  not 
a  common  symptom  in  infants  and  young  children,  and  is  not  seen 
in  the  acute  disturbances  of  digestion  or  in  infectious  diarrhea.  Be- 
side appendicitis  it  is  seen  most  often  in  intussusception  and  lobar 
pneumonia.  Intussusception  is  excluded  by  the  other  pecuHarities 
of  its  symptom-complex,  such  as  bloody  intestinal  discharges,  and 
the  finding  of  a  definite  rounded  tumor.  The  diagnosis  between 
appendicitis  and  early  lobar  pneumonia  is  often  very  difficult.  Pneu- 
monia is  much  more  often  mistaken  for  appendicitis  than  vice  versa. 
In  appendicitis  the  rate  of  respiration  is  not  so  much  accelerated 
as  in  pneumonia,  vomiting  is  a  more  pronounced  and  persistent 
symptom,  and  the  abdominal  tenderness,  while  it  may  not  be  local- 
ized in  the  right  iHac  region,  is  usually  accompanied  by  involuntary 
muscular  spasm,  which  sign  is  absent  in  pneumonia.  The  diagnosis 
may  be  in  doubt  until  the  signs  of  pneumonia  appear  in  the  lungs. 
Paroxysmal '  pain,  continued  vomiting,  and  increasing  prostration 
point  toward  appendicitis. 

In  those  cases  in  which  abdominal  tenderness  cannot  be  made  out, 
the  diagnosis  is  often  still  more  difficult.  It  usually  depends  on  the 
combination  of  fever,  vomiting,  constipation,  pain,  especially  if 
paroxysmal,  and  the  absence  of  any  evidence  of  other  adequate  cause 
for  the  symptoms. 

I  have  seen  appendicitis  in  which  fever,  vomiting,  and  acetonuria 
were  the  main  symptoms,  mistaken  for  acidosis  until  after  general 
peritonitis  had  developed. 

PROGNOSIS. — The  prognosis  depends  largely  upon  how  early 
the  diagnosis  is  made  and  the  skill  of  the  surgeon  who  is  called  for 
consultation  and  operation.  Cases  undoubtedly  recover  in  many 
instances  without  operation,  but  the  extreme  gravity  of  the  results 
of  an  extension  of  the  inflammation  to  the  peritoneum,  and  the 
realization  that  this  accident  may  occur  at  almost  any  time,  even  in 
the  cases  which  are  apparently  running  a  mild  course,  render  general 
statistics  of  little  value  in  the  consideration  of  an  individual  case. 
We  should  not  lose  sight  of  the  fact  that  in  infancy  we  see  most 
frequently  the  very  severe  and  acute  forms  of  the  disease,  and  there 
is  the  special  tendency  to  perforation  and  gangrene  and  extension 
to  the  peritoneum,  with  its  very  serious  consequences. 


Appendicitis  495 

TREATMENT. — I  believe  that  every  case  of  appendicitis  in 
children  should  be  operated  upon  as  soon  as  the  diagnosis  is  made. 
The  danger  of  delay  is  greater  in  children  than  in  adults,  because  the 
disease  may  be  so  much  more  insidious  in  its  onset  and  course, 
that  gangrene,  perforation,  and  peritonitis  may  occur  with  very  little 
warning.  Consequently,  if  the  diagnosis  of  appendicitis  can  be  made, 
or  if  it  is  even  suspected,  the  surgeon  should  be  called  in  immediately. 
If  the  diagnosis  is  fairly  clear,  no  time  should  be  wasted  with  blood 
counts,  or  with  observation  of  the  progress  of  the  case.  The  opera- 
tion should  be  promptly  performed.  I  have  seen  serious  mistakes 
made  in  waiting  too  long  by  surgeons  who  were  more  familiar  with 
the  disease  as  it  manifests  itself  in  adults  than  in  children.  There 
is  no  medical  treatment  other  than  that  which  is  purely  symptomatic. 
Absolute  rest  in  bed,  irrespective  of  the  severity  of  the  symptoms, 
is  of  first  importance;  local  appHcations  of  ice  should  be  used  to 
control  the  pain,  or,  if  the  child  objects,  as  is  frequently  the  case, 
hot  fomentations  should  be  tried.  Cathartics  and  laxatives  should 
be  avoided,  and  the  bowels  moved  by  enemata.  Blisters  should  not 
be  used.  Opium  is  strongly  objected  to  by  surgeons  as  tending  to 
mask  the  symptoms;  if  it  can  be  avoided,  it  is  far  better  to  do  so; 
but  very  small  doses,  sufficient  to  keep  the  patient  from  excessive 
pain  and  fairly  quiet,  are  probably  in  children  a  lesser  danger  than 
that  which  would  be  caused  by  hours  of  pain,  crying,  and  intense 
restlessness. 


VIII.     UNCLASSIFIED  DISEASES 

Under  this  heading  will  be  considered  certain  conditions  which 
cannot  be  classified  under  any  of  the  foregoing  groups,  because  their 
etiology  is  either  unknown,  or  exceptional,  or  very  varied. 

CONSTIPATION 

Constipation  is  a  condition  in  which  the  number  of  stools  passed 
is  less  than  the  normal,  or  in  which  the  consistency  of  the  stools  is 
greater  than  the  normal.  It  is  not  a  disease,  but  a  symptom.  To 
recognize  constipation  one  must  be  familiar  with  the  normal  number 
and  consistency  of  the  intestinal  discharges  in  the  various  periods 
of  early  Hfe.  During  the  first  year  of  life,  the  normal  daily  number 
of  evacuations  is  two  or  three  in  breast-fed  infants,  and  one  to  three 
in  the  artificially-fed.  The  consistency  is  normally  somewhat  greater 
in  the  artificially-fed,  but  should  not  be  so  great  as  to  cause  any 
evidences  of  discomfort  on  passage.  In  the  second  year  the  normal 
number  of  discharges  daily  is  one  or  two,  and  in  later  childhood 
one  is  the  usual  number. 

ETIOLOGY.— The  causes  of  constipation  are  very  numerous  and 
varied,  and  often  the  condition  is  due  to  the  joint  action  of  several 
causes.  It  is  difficult  to  make  a  satisfactory  classification  of  the 
various  kinds  of  constipation,  and  the  various  etiological  factors 
involved.  The  following  classification,  while  not  logically  consistent 
in  every  respect,  is  convenient  for  reference  in  the  diagnosis  of  a 

given  case. 

Table  47 

Causes  of  Constipation 

[Heredity 

1 .  Constitutional i  Thyroid  insufficiency 

[Backward  development 

[Long  colon 

2.  Mechanical | Intestinal  lesion 

[Obstruction  from  pressure 

[Fissure  of  anus 

3.  Reflex  (spasmodic) -^Hemorrhoids 

[Large,  hard  stools 

4.  Partial  paralysis fOpium 

\Acute  infectious  disease 


5.  Dietary. 


Too  weak  food 
Too  little  fat 
Excess  of  fat 
Heating  of  milk 
Too  little  solids 


Constipation  497 


Table  47 — Continued 
6.  Muscular  weakness  (atonic) 


Prolonged  indigestion 

Malnutrition 

Rachitis 

Lack  of  exercise 

Abuse  of  laxatives 

Lack  of  proper  training 


Constitutional  Causes. — There  is  no  doubt  that  certain  children 
have  a  constitutional  tendency  toward  constipation,  which  often 
appears  during  early  infancy.  There  are  so  many  instances  in  which 
constipation  is  seen  in  both  parent  and  child,  without  other  obvious 
cause,  that  it  is  probable  that  heredity  plays  some  part.  Neverthe- 
less, the  possibihty  of  coincidence  cannot  be  overlooked,  and  it  is 
probable  that  the  part  played  by  heredity  is  a  minor  one.  Thyroid 
insufficiency  is  a  possibility  which  must  not  be  forgotten  in  infancy. 
In  a  marked  case  of  cretinism,  the  cause  of  the  constipation  would 
not  be  overlooked,  but  in  many  cases  the  characteristic  stigmata 
are  slight  or  absent.  It  is  probable  that  a  relative  backwardness  of 
the  functional  development  of  the  digestive  glands,  such  as  the  liver 
and  intestinal  glands,  may  be  a  contributing  cause  in  some  cases 
in  young  infants. 

With  the  exception  of  insufficiency  of  the  thyroid,  the  causes  in 
this  group  can  neither  be  recognized,  nor  removed,  and  must  be 
regarded  as  representing  an  underlying  constitutional  factor,  which 
in  the  case  of  heredity  is  permanent,  and  in  the  case  of  backward 
development  is  temporary.  The  treatment  of  constipation  from 
thyroid  insufficiency  is  that  of  cretinism. 

Mechanical  Causes. — The  large  intestine,  especially  the  sigmoid 
flexure,  in  the  infant  is  relatively  longer  than  in  later  life,  and  has 
a  proportionately  longer  mesentery.  This  allows  more  opportunity 
for  bends  and  kinks,  and  may  be  a  constant  contributing  cause  in 
the  constipation  of  infancy.  In  some  cases,  the  colon  may  be  abnor- 
mally long.  There  may  be  a  congenital  lesion  involving  some  portion 
of  the  intestine,  such  as  a  partial  stenosis,  a  Jackson's  membrane,  or 
peritoneal  adhesions  resulting  from  some  inflammatory  process  before 
or  after  birth  Such  adhesions  are  not  very  rare  in  post-mortems  of 
infants.  Hirschprung's  disease  is  a  recognized  mechanical  cause  of 
constipation.  Moreover,  some  lesion  not  directly  involving  the 
intestine,  such  as  tumor,  may  cause  mechanical  obstruction  from 
pressure. 

Some  of  the  mechanical  causes,  such  as  tumor  and  Hirschprung's 
disease,  may  be  recognized  by  physical  examination.  Usually,  how- 
ever, the  recognition  of  a  mechanical  cause  for  constipation  depends 
on  the  examination  of  roentgenograms  taken  after  bismuth  meals  and 
bismuth  rectal  injections.  Some  mechanical  causes  cannot  be 
diagnosed. 
32 


498  Diseases  of  the  Gastro-Enteric  Tract 

Reelex  Causes. — Mechanical  irritation,  usually  in  the  rectum  or 
at  the  anus,  may  produce  a  spasm  of  the  musculature  of  the  intes- 
tinal walls.  This  is  the  so-called  spasmodic  form  of  constipation. 
It  is  seen  in  such  conditions  as  fissure  of  the  anus,  or  hemorrhoids. 
The  passage  of  large,  hard  stools  is  perhaps  the  most  frequent  cause 
of  spasmodic  constipation.  The  other  causes  of  constipation  must 
be  sought  in  explanation  of  the  hard  stools. 

The  reflex  causes  of  constipation  are  recognized  by  examination. 

PARTLA.L  Paralysis. — Constipation  may  be  caused  by  a  paralysis 
of  peristalsis,  coming  not  from  muscular  weakness,  but  from  impaired 
innervation.  This  is  the  probable  explanation  of  the  symptomatic 
constipation  seen  in  acute  infectious  disease.  The  same  sort  of  con- 
stipation is  seen  as  the  result  of  the  administration  of  opium,  usually 
in  the  form  of  paregoric  or  some  ''soothing  syrup."  The  possi- 
bihty  of  this  cause  must  always  be  remembered.  Sometimes  a  nurse 
may  be  giving  some  form  of  opium  to  quiet  the  baby  without  the 
knowledge  of  the  parents. 

In  acute  infectious  disease,  the  cause  of  the  symptom  is  obvious. 
The  recognition  of  opium  depends  on  the  history,  or  on  the  detective 
investigation  of  the  physician. 

Dietary  Causes. — This  group  includes  causes  which  are  far  com- 
moner than  any  of  the  foregoing.  In  infants  the  commonest  dietary 
cause  is  insufficient  food.  The  milk  may  be  insufficient  in  quan- 
tity, or  may  be  too  weak  in  composition.  This  cause  is  met  with 
both  in  breast-fed  infants  and  in  the  artificially-fed.  The  infants  are 
constipated,  because  the  soHds  of  the  food  are  so  completely  absorbed 
that  not  enough  residue  is  left  to  form  the  normal  amount  of  feces. 
Constipation  may  also  occur  when  the  food  contains  insufficient  fat. 
The  fat  forms  the  principal  bulk  of  the  feces  in  infants,  and  if  the 
carbohydrate  and  protein  be  completely  absorbed,  there  is  not  enough 
fecal  matter.  An  excess  of  fat  is,  however,  a  more  common  cause  of 
constipation  in  artificially-fed  infants.  In  this  instance  the  bulk  of 
the  stools  is  not  diminished,  nor  is  the  number  of  discharges,  but 
the  stools  are  large  and  hard.  The  Hght  yellow  or  gray  color,  and 
occasional  dry,  crumbHng  consistency  of  the  "soap  stools"  have  been 
described  under  indigestion  from  an  excess  of  fat.  An  excess  of 
starch  in  the  food  may  cause  constipation,  but  in  this  instance  the 
symptom  is  due  to  muscular  weakness  from  the  effects  of  prolonged 
fermentation.  In  older  children  constipation  may  be  seen  in  indi- 
gestion from  an  excess  of  sugar,  but  this  form  is  also  due  to  muscular 
weakness,  and  will  be  described  in  the  next  group.  The  heating  of 
milk,  especially  if  the  milk  be  boiled  or  sterilized  instead  of  pasteur- 
ized, may  be  a  cause  of  constipation,  but  this  cause  is  less  common 
than  is  generally  supposed,  and  has  never  actually  been  proven. 


Constipation  499 

In  older  children  constipation  may  be  caused  by  a  faulty  diet. 
One  fault,  seen  mainly  in  the  second  year,  is  the  giving  of  too  much 
milk.  A  baby  of  this  age  is  sometimes  so  fond  of  milk  that  it  is 
given  more  than  it  should  have,  or  the  mother  is  fearful  that  solid 
food  will  cause  digestive  disturbance,  and  believes  that  milk  is 
"safer."  A  baby  in  the  second  year  should  not  take  more  than 
forty  ounces  of  milk  in  the  twenty-four  hours.  Another  dietary 
fault  in  older  children  is  the  giving  of  an  insufficient  amount  of  cereal, 
cooked  fruit,  and  green  vegetables. 

The  dietary  causes  of  constipation  are  recognized  by  a  careful 
and  painstaking  inquiry  into  every  detail  of  the  child's  diet. 

Muscular  Weakness. — Muscular  weakness  is  not  a  primary 
cause  of  constipation,  but  a  condition  secondary  to  a  variety  of 
causes.  This  is  the  well-known  "atonic"  form  of  constipation, 
which  is  one  of  the  commonest  encountered  in  early  life.  The  essen- 
tial condition  is  a  weakness  or  atony  of  the  muscles  of  the  intestinal 
wall.  Weakness  of  the  muscles  of  the  abdominal  wall  is  not  infre- 
quently an  accompanying  condition  and  contributing  factor.  Prob- 
ably the  commonest  cause  is  prolonged  indigestion,  especially  when 
due  to  an  excess  of  carbohydrate.  While  carbohydrate  indigestion 
in  infants  produces  loose  movements  from  the  irritating  products 
of  fermentation,  the  excessive  gas  formation  and  intestinal  distention 
causes  an  atony  of  the  intestinal  muscles,  which  will  later  result  in 
constipation.  This  is  especially  common  in  the  carbohydrate  indi- 
gestion of  older  children.  Moreover,  in  many  chronic  digestive 
disturbances,  and  in  many  other  chronic  diseases,  malnutrition, 
involving  all  the  tissues  of  the  body  is  a  common  condition.  The 
muscles  of  the  intestinal  wall  and  the  abdominal  muscles  are  involved 
in  this  general  wasting,  and  muscular  atony  is  the  result.  One  form 
of  disturbed  nutrition,  in  which  atonic  constipation  is  very  common, 
is  rickets. 

Lack  of  exercise  leads  to  general  muscular  atony,  and  the  muscles 
of  the  intestine  are  also  involved.  This  cause  is  not  confined  to 
older  children,  for  infants  are  often  kept  too  quiet,  and  not  allowed 
to  kick  and  use  their  limbs.  Another  cause  is  lack  of  training.  While 
still  in  infancy,  children  can  be  taught  to  empty  the  bowel  at  a  regu- 
lar and  proper  time,  and  this  training  should  be  carried  out  as  early 
as  possible.  With  older  children  it  is  essential  that  the  child  be 
not  allowed  to  wait  until  the  spirit  moves  him  to  evacuate  the  bowels, 
but  that  he  should  be  made  to  go  to  the  water  closet  at  a  regular 
time  each  day,  preferably  after  breakfast  in  the  morning.  If  this 
is  not  done,  children  will  often  develop  constipation  through  neg- 
lecting their  bowels,  as  they  allow  their  various  absorbing  interests 
to  make  them  postpone  going  to  the  water  closet  even  when  they 
feel  the  impulse.     Muscular  atony  will  in  time  follow  such  neglect. 


500  Diseases  of  the  Gastro-Enteric  Tract 

The  atonic  form  of  constipation  can  be  recognized  only  from  a 
very  careful  history  of  the  case,  including  every  detail  of  the  child's 
daily  Hfe. 

SYMPTOMS. — The  general  symptoms  caused  by  constipation  in 
children  are  indefinite,  variable  in  kind  and  severity,  and  sometimes 
entirely  absent.  In  infancy,  the  only  symptom  may  be  signs  of 
general  discomfort,  irritabihty,  and  sometimes  sleeplessness.  The 
trouble  may  sometimes  be  recognized  only  by  the  straining  and 
effort  which  accompanies  defecation.  In  some  cases  flatulence  and 
colic  are  the  most  prominent  symptoms.  In  older  children  the  most 
prominent  symptoms  are  either  a  tendency  to  headaches,  or  abdom- 
inal pain  and  cUscomfort.  In  both  infancy  and  childhood,  a  coated 
tongue  and  bad  breath  are  frequent  symptoms.  None  of  these 
symptoms  is  peculiar  to  constipation,  nor  in  any  way  diagnostic. 
There  are  often  no  general  symptoms,  and  this  is  particularly  likely 
to  be  the  case  when  the  constipation  is  due  to  atony  of  the  lower 
part  of  the  intestine. 

Pain  is  almost  always  present  in  the  spasmodic  form,  and  is  usu- 
ally present  in  the  type  characterized  by  the  passage  of  large,  hard 
stools.  In  this  type  streaks  of  blood  with  the  feces  are  not  un- 
common. 

DIAGNOSIS. — Constipation  being  a  symptom,  its  diagnosis  is 
of  course  obvious.  The  important  thing  is  the  diagnosis  of  the 
etiology  of  the  condition.  This  depends  on  a  thorough  knowledge 
of  all  the  various  possible  etiological  factors.  It  demands  a  very 
careful  history,  which  should  include  every  detail  concerning  the 
child's  diet,  habits,  and  daily  hfe.  A  most  thorough  physical  ex- 
amination, which  should  usually  include  a  rectal  examination,  should 
be  made  in  every  case.  Roentgenograms,  taken  after  a  bismuth 
meal,  or  a  bismuth  enema,  constitute  an  important  diagnostic  pro- 
cedure, and  should  be  employed  in  every  case  in  which  the  etiology 
is  not  immediately  obvious. 

PROGNOSIS. — The  prognosis  of  constipation  depends  on  the 
etiological  factors  involved.  In  some  cases  due  to  easily  removable 
causes,  such  as  improper  diet,  or  the  use  of  opium,  the  prognosis  for 
immediate  improvement  is  good.  Such  causes  as  insufiicient  exercise, 
lack  of  proper  training,  and  the  abuse  of  laxatives  are  removable, 
but  when  they  have  resulted  in  the  development  of  the  atonic  form 
of  constipation,  the  process  of  recovery  is  much  slower,  and  while 
the  eventual  prognosis  is  good,  considerable  time  is  often  required 
before  improvement  is  noted.  The  prognosis  of  constipation  secon- 
dary to  other  diseases  is  that  of  the  causative  condition,  but  here 
again,  if  such  causes  as  malnutrition  or  prolonged  indigestion  have 
resulted  in  the  atonic  form  of  constipation,  recover}"  is  comparatively 


Constipation  501 

slow.  In  cases  in  which  heredity  plays  an  important  part,  the  ten- 
dency toward  constipation  is  more  persistent,  but  even  in  such  cases, 
backward  development  usually  plays  some  role,  and  the  tendency 
may  be  outgrown  in  time.  In  cases  due  to  a  lesion  of  the  intestine, 
the  prognosis  depends  on  the  possibiUty  of  removing  the  cause. 

TREATMENT.  Removal  of  the  Cause.— The  treatment  of 
constipation  is  removal  of  the  cause,  or  treatment  of  the  cause. 
Such  causes  as  heredity,  and  backward  development  cannot,  of  course, 
be  removed  or  treated.  On  the  other  hand,  such  causes  as  cretinism 
and  the  abuse  of  drugs  can  be  quickly  remedied.  Such  mechanical 
causes  as  anatomical  lesions  involving  the  intestine,  can  only  be 
remedied,  if  at  all,  by  some  radical  surgical  operation.  When  consti- 
pation is  due  to  the  long  infantile  colon,  only  time  and  growth  can 
remove  the  cause.  Both  fissure  of  the  anus  and  hemorrhoids  are 
easily  cured  in  childhood;  during  the  treatment  the  stools  must  be 
kept  soft  with  some  mild  laxative.  In  the  type  of  spasmodic  consti- 
pation due  to  the  passage  of  large,  hard  stools,  the  first  cause  is 
dietetic,  and  the  treatment  is  that  of  the  cause.  The  treatment  of 
the  symptomatic  constipation  seen  in  acute  infectious  diseases  is 
described  under  the  diseases  in  which  it  occurs.  It  consists  in  the 
use  of  enemata,  or  of  mild  laxatives.  In  infants  with  acute  infectious 
disease,  the  bowels  can  be  kept  properly  open  with  magnesia.  In 
older  children,  sodium  phosphate,  cascara,  or  phenolphthalein,  are 
required.  Constipation  due  to  recognizable  dietary  errors  is  easily 
remedied  by  removal  of  the  cause.  When  the  cause  is  some  under- 
lying chronic  disease,  such  as  prolonged  indigestion,  malnutrition 
and  rickets,  the  treatment  is  that  of  the  cause.  Such  causes  as 
lack  of  exercise,  lack  of  training,  and  the  abuse  of  laxatives  are 
removable. 

Dietetic  Treatment. — In  many  cases  of  constipation,  the  cause 
cannot  be  immediately  remedied,  but  the  underlying  disease  requires 
prolonged  treatment.  In  other  cases,  while  the  cause  can  be  re- 
moved, its  removal  is  not  followed  by  immediate  relief  of  symptoms. 
This  is  particularly  true  when  the  constipation  is  of  the  atonic  type. 
It  becomes  necessary  to  treat  the  constipation  in  the  meantime. 
The  treatment  of  constipation  is  mainly  dietetic. 

The  measures  employed  to  improve  a  weak  breast-milk  have  been 
described  in  the  division  on  Feeding.  In  artificially-fed  infants, 
changes  may  be  made  in  the  composition  of  the  food,  with  a  view  to 
finding  the  combination  of  the  food  elements  best  suited  to  the 
needs  of  the  individual  baby.  The  food  may  be  cautiously  strength- 
ened in  composition,  while  signs  of  indigestion  are  carefully  watched 
for.  It  is  not,  however,  a  good  plan,  in  a  baby  who  is  digesting  well, 
and  gaining  weight,  to  make  much  change  in  the  composition  of  the 


502  Diseases  of  the  Gastro-Enteric  Tract 

food.  It  is  particularly  dangerous  to  increase  the  quantity  of  cow's 
milk  fat  in  the  food,  simply  for  the  purpose  of  treating  constipation. 
Only  in  cases  where  the  baby  is  getting  less  food  or  less  fat  than  he 
can  digest,  is  it  safe  to  make  much  increase.  The  feeding  of  an 
infant  is  guided  by  his  digestive  peculiarities,  and  there  is  compara- 
tively little  room  for  treating  the  constipation  of  infancy  by  dietetic 
measures,  beyond  the  correction  of  an  error.  In  some  cases  the 
substitution  of  a  maltose-dextrin  preparation  in  place  of  lactose  will 
have  a  good  effect  on  constipation.  For  this  purpose  the  malt  ex- 
tracts are  better  than  the  dry  dextri-maltose  preparations.  Orange 
juice  may  be  given  to  infants  in  the  second  half  of  the  first  year.  Also, 
at  this  age,  oatmeal  water  or  oatmeal  jelly  may  often  be  advantage- 
ously substituted  for  barley  water. 

In  the  second  year  there  is  more  scope  for  dietetic  treatment. 
The  amount  of  milk  may  be  slightly  reduced,  but  cream  should  not 
be  substituted,  because  while  the  giving  of  more  cream  will  improve 
the  constipation,  it  may  cause  indigestion  in  a  very  insidious  way. 
The  slight  reduction  in  milk  should  be  made  up  by  an  increase  in 
the  amount  of  sohd  food.  The  coarser  farinaceous  foods  are  valuable 
as  peristaltic  stimulants.  Graham  bread  should  be  substituted  for 
white  bread,  graham  crackers  may  be  substituted  for  zwieback,  and 
oatmeal  should  be  the  preferred  cereal.  Meat  broths  and  beef  juice 
are  valuable  on  account  of  the  laxative  effect  of  their  salts  and  ex- 
tractives. Fruits  are  valuable,  but  only  the  juice  should  be  given 
until  the  child  is  over  fifteen  months.  Between  the  fifteenth  and 
eighteenth  months  baked  apple,  apple  sauce,  or  prune  pulp  may  be 
given  daily.  Toward  the  end  of  the  second  year  a  Httle  of  the  green 
vegetables,  such  as  spinach,  string  beans,  and  asparagus  may  be 
cautiously  tried. 

In  older  children  the  quantity  of  milk  may  be  reduced,  and  also 
the  quantity  of  starchy  food.  Graham  bread  should  be  used,  and 
bran  biscuits  are  often  valuable.  Meat  and  broth  may  be  given 
freely.  One  of  the  green  vegetables  should  be  given  every  day. 
Cooked  fruit  of  any  kind  should  be  given,  but  raw  fruit  not  until 
the  child  is  over  three  years  of  age.  Care  must  be  taken,  however,, 
not  to  produce  indigestion  by  the  giving  of  too  much  fruit  and  coarse 
food.  Plenty  of  water  should  be  given  between  meals.  It  is  often 
a  good  plan  to  give  a  half  a  glass  of  some  sparkling  water,  such  as 
Apollinaris,  an  hour  before  breakfast. 

Other  General  Measures. — It  is  essential  that  regular  habits 
in  connection  with  the  evacuation  of  the  bowels  be  established. 
Even  in  babies,  training  is  not  difficult.  The  baby  should  be  put  in 
a  properly  constructed  chair  at  a  regular  hour  each  day,  and  a  sup- 
pository made  from  a  roll  of  paper  dipped  in  sweet  oil,  or  a  soap 
suppository,  should  be  inserted  to  supply  a  local  stimulus.     As  soon 


Constipation  503 

as  the  habit  is  established,  the  suppositories  should  be  omitted,  or 
the  baby  may  easily  become  dependent  on  them.  Older  children 
should  be  trained  never  to  neglect  an  impulse  to  evacuate  the  bowels 
and  should  be  made  to  go  to  the  water  closet  every  morning  imme- 
diately after  breakfast. 

Massage  of  the  abdomen  is  useful  as  a  routine  treatment,  but 
should  not  be  relied  on  without  other  measures.  It  should  be  given 
for  five  minutes  just  after  the  child  goes  to  bed,  and  just  before 
it  gets  up.  The  hand  should  not  be  oiled,  and  the  skin  should  not 
be  rubbed,  but  the  hand  and  abdominal  wall  should  roll  together 
over  the  deeper  structures. 

Medicinal  Treatment. — Laxatives  must  be  used,  when  other 
measures  do  not  suffice.  The  best  laxative  for  an  infant  is  milk 
of  magnesia,  and  it  is  often  required,  because  of  the  limitations  of 
dietetic  treatment  at  this  age.  It  is  better  not  to  give  the  milk  of 
magnesia  in  a  single  daily  dose,  but  to  divide  the  daily  amount  so 
that  it  is  given  in  all  the  food  taken  by  the  infant.  In  a  breast- 
fed infant,  the  magnesia  may  be  given  in  a  teaspoonful  of  water  im- 
mediately before,  or  during,  each  nursing.  In  an  artificially-fed 
baby,  the  magnesia  may  be  put  into  every  bottle.  The  daily  amount 
to  begin  with  should  be  a  teaspoonful,  and  this  should  be  so  divided 
that  a  baby  receiving  six  feedings  should  have  ten  drops  of  milk  of 
magnesia  put  into  every  bottle,  or  given  before  each  nursing.  The 
number  of  drops  thus  given  in  each  feeding  should  be  increased  or 
diminished  according  to  circumstances,  until  just  the  right  quantity 
is  found  to  cause  a  daily  normal  evacuation  of  the  bowels.  The 
minimum  amount  which  will  produce  this  effect  should  always  be 
used,  and  as  the  constipation  improves,  an  effort  should  be  made 
to  reduce  the  amount  of  magnesia  till  it  can  be  omitted  altogether. 
The  advantage  of  giving  milk  of  magnesia  in  this  way  is  obvious. 
Any  laxative  in  a  child,  when  given  in  single  daily  doses,  produces 
a  maximum  stimulus,  and  tends  to  make  the  patient  dependent  on 
the  drug.  When  milk  of  magnesia  is  given  in  the  food,  the  effect 
is  to  make  all  the  food  more  laxative,  and  this  is  just  Uke  dietetic 
treatment,  and  is  just  the  result  which  we  wish  to  obtain  in  infants. 

This  method  of  administering  milk  of  magnesia  may  also  be  used 
in  the  second  year.  When  a  daily  amount  of  two  or  three  teaspoon- 
fuls  given  in  divided  doses  in  the  milk  fails  to  produce  a  satisfactory 
result,  sodium  phosphate  should  be  substituted.  It  should  be  given 
divided  in  the  same  way  m  the  milk,  the  twenty-four  amount  being 
sixty  to  ninety  grains. 

When  both  milk  of  magnesia  and  sodium  phosphate  fail  to  pro- 
duce the  desired  result,  the  child  is  usually  over  eighteen  months 
old,  and  the  variety  of  its  diet  makes  dietetic  measures  more  effec- 
tive, so  that  it  is  less  necessary  to  give  the  laxative  in  the  food.     In 


504  Diseases  of  the  Gastro-Enteric  Tract 

cases  of  this  kind,  and  in  older  children  in  general,  the  two  best  lax- 
atives for  chronic  constipation  are  phenolphthalein  and  cascara  sagrada. 
Here  again  it  is  preferable  to  give  the  laxative  three  times  a  day 
with  the  meals,  but  often  a  satisfactory  result  cannot  be  obtained 
in  this  way.  In  such  cases,  the  laxative  should  be  given  at  bed- 
time. The  dose  of  phenolphthalein  is  from  one  to  three  grains,  and 
of  cascara  from  one-half  to  two  grains,  or  from  five  to  twenty  drops 
of  the  fluid  extract. 

Olive  oil,  in  doses  of  a  teaspoonful  three  times  a  day,  is  some- 
times useful  both  in  infants  and  in  older  children.  Agar  agar  is 
useful  in  older  children  who  pass  hard,  dry  stools.  It  should  be 
given  finely  divided,  in  doses  of  one  to  three  teaspoonfuls  three  times 
a  day.  In  some  cases  of  atonic  constipation,  a  combination  of  aloin, 
extract  of  nux  vomica,  and  strychnine,  in  small  doses  appropriate 
to  the  age  of  the  child,  is  very  valuable.  It  may  be  given  as  a  tonic, 
and  if  it  does  not  sufiice  to  overcome  the  constipation,  cascara  or 
phenolphthalein  may  be  given  in  addition.  To  a  child  two  or  three 
years  old,  the  combination  may  be  aloin  gr.  1/24,  ext.  nux  vomica 
gr.  1/24,  ext.  belladonnae  gr.  1/48. 

The  medicinal  remedies  to  be  especially  avoided  in  the  chronic 
constipation  of  early  Ufe  are  castor  oil,  calomel,  senna,  compound 
liquorice  powder,  and  rhubarb.  All  of  them  cause  too  violent  a 
stimulation  of  peristalsis,  and  are  not  adapted  for  prolonged  use, 
as  they  tend  to  increase  the  tendency  toward  constipation,  and  to 
make  the  child  dependent  upon  medicine.  They  are  adapted  only 
for  temporary  use,  in  such  conditions  as  acute  disease.  Even  when 
cascara  or  phenolphthalein  are  used  in  chronic  constipation,  a  con- 
stant effort  should  be  made  to  reduce  the  amount  of  laxative.  With 
the  other  measures,  and  treatment  or  removal  of  the  underlying 
cause,  this  will  usually  be  possible. 

Suppositories. — Suppositories  are  best  adapted  to  the  form  of 
constipation  in  infancy  in  which  the  weakness  is  low  down  in  the 
intestine.  This  form  can  be  recognized  by  the  immediate  passage 
of  a  large  movement  whenever  a  suppository  is  used.  Treatment 
with  suppositories  should  be  confined  to  this  form  of  constipation, 
and  should  not  be  used  for  atony  of  the  upper  bowel.  Infants  be- 
come dependent  on  suppositories  just  as  easily  as  upon  drugs.  Gluten 
suppositories  are  the  least  irritating.  Soap  suppositories  are  allow- 
able, but  glycerin  suppositories  should  never  he  used  in  chronic  consti- 
pation. I  have  seen  more  cases  of  chronic  constipation  caused  by 
glycerin  suppositories,  than  by  the  abuse  of  any  laxative. 

Enemata. — These  are  not  advisable  in  the  treatment  of  chronic 
constipation  in  general.  They  are,  however,  useful  in  constipation 
due  to  a  temporary  cause,  such  as  the  symptomatic  constipation 


Intestinal  Worms  505 

of  acute  disease.  The  ordinary  soap  suds  enema  is  the  best  in  such 
cases.  When  the  stools  are  very  hard  and  dry,  an  injection  of  an 
ounce  of  sweet  oil  at  bedtime  may  facilitate  their  passage.  Cases 
of  fecal  impaction  are  rare  in  children,  but  cases  are  sometimes  seen 
in  which  there  is  a  great  deal  of  hard  fecal  accumulation,  the  bowels 
not  having  moved  for  several  days!  In  such  cases,  an  injection  of 
an  ounce  of  sweet  oil  may  be  given,  to  be  followed  in  half  an  hour 
by  a  soap-suds  enema. 

It  is  sometimes  necessary  to  cause  an  immediate  emptying  of  the 
lower  bowel  by  means  of  an  enema.  Under  such  circumstances  an 
enema  of  two  teaspoonfuls  of  glycerin  in  an  ounce  of  water,  is  very 
efl&cient.  Glycerin  enemata  are  strongly  contraindicated  in  chronic 
constipation. 

INCONTINENCE  OF  FECES 

Incontinence  of  feces  is  a  condition  in  which  the  fecal  move- 
ments occur  involuntarily.  This  may  be  due  to  inabiUty  to  control 
the  sphincter  ani,  or  to  loss  of  power  of  the  sphincter  itself.  The 
first  class  of  cases,  due  to  disease  or  injury  of  the  spinal  cord,  or  to 
absence  of  reflex  sensation,  is  rare.  The  second  class  is  due  to  an 
atonic  condition  of  the  sphincter.  The  treatment  of  the  first  class 
of  cases  is  essentially  that  of  the  disease  in  which  it  occurs.  The 
treatment  of  the  second  class  is  illustrated  in  the  following  cases: 

A  boy,  eleven  years  old,  much  overworked  at  school,  had  been  made  to  study  a 
number  of  languages,  and  allowed  to  take  only  a  very  limited  amount  of  exercise  in 
the  open  air.  He  completely  lost  control  of  the  sphincter  ani,  and  became  very  anemic 
and  weak.  Nothing  abnormal  was  found  on  a  physical  examination.  The  boy  was. 
taken  from  school,  relieved  entirely  of  his  studies,  and  kept  in  the  open  air  most  of  the 
day.  Under  this  treatment,  in  addition  to  the  administration  of  tartrate  of  iron  and 
potassium,  he  improved  rapidly,  and  in  two  months  was  entirely  well. 

Another  boy,  seven  years  old,  came  to  the  Children's  Hospital,  with  a  history  of 
incontinence  of  feces  lasting  over  a  year.  He  illustrated  the  condition  of  incontinence 
from  habitual  constipation,  as  the  incontinence  was  found  to  depend  on  the  stretching 
of  the  rectum  by  impacted  feces.  The  rectum  was  emptied  by  a  dose  of  castor  oil  and 
an  enema  each  day.  At  the  end  of  a  week  the  boy  had  ceased  to  have  involuntary  fecal 
movements,  and  has  since  continued  well. 

INTESTINAL  WORMS 

The  worms  which  are  found  in  the  intestines  of  infants  and  chil- 
dren are  the  same  as  those  which  occur  in  older  patients.  The 
only  ones,  however,  which  are  common  and  important  enough  to 
be  described  are  the  oyxuris  vermicularis  (pin-worm) ,  the  ascaris 
lunibricoides  (round  worm),  the  taenia  solium,  and  the  taenia  saginata 
or  mediocanellata  (tapeworms). 

OXYURIS  VERMICULARIS 

The  oxyuris  vermicularis  is  a  minute  worm,  which  looks  like  a 
little  piece  of  white  thread.  The  female  is  from  1/4  to  1/2  inch 
in  length.     The  male  is  about  one-third  as  large,  and  has  a  tail 


506  Diseases  of  the  Gastro-Enteric  Tract 

rolled  into  a  spiral.  Their  development  takes  place  in  the  large 
intestine,  and  the  mature  worms  deposit  their  eggs  in  the  rectum. 
The  eggs  enter  the  intestine  through  the  mouth,  and  children  are 
very  apt  to  reinfect  themselves  by  carrying  the  eggs  on  the  fingers 
or  under  the  nails  to  their  mouths. 

These  worms  sometimes  exist  in  large  numbers,  and  their  develop- 
ment is  so  rapid  that  it  is  often  difficult  to  dislodge  them  completely. 
The  most  common  symptom  of  the  oxyuris  is  an  intense  itching 
about  the  anus.  The  sleep  of  the  child  is  disturbed  by  this  irrita- 
tion, and  various  nervous  symptoms  develop  in  children  who  are 
infested  with  this  parasite.  Thus  incontinence  of  urine  sometimes 
results.  In  girls  the  parasite,  by  migrating  from  the  anus  to  the 
vulva,  may  cause  a  vulvo-vaginitis. 

DIAGNOSIS. — The  diagnosis  of  the  presence  of  these,  as  of  other 
intestinal  parasites,  can  be  made  only  by  finding  the  worms  or  their 
ova  in  the  intestinal  discharges.  When  they  are  suspected,  an  enema 
of  clear  water  should  be  given.  If  the  parasites  are  present,  they 
will  be  dislodged,  and  careful  inspection  will  disclose  their  presence. 
Whenever  there  are  symptoms  of  reflex  irritation  in  the  neighborhood 
of  the  anus  or  the  genital  organs,  the  oxyuris  should  be  suspected 
and  sought  for.  The  parasites  can  often  be  found  in  the  fecal  dis- 
charges, and  in  some  cases  they  can  be  seen  by  simply  stretching 
open  the  anus  and  examining  the  mucous  membrane  of  the  rectum, 
especially  if  this  be  done  when  the  child  is  in  bed  at  night. 

TREATMENT. — Although  most  of  the  worms  are  in  the  rectum, 
yet  they  also  infect  the  upper  parts  of  the  intestine,  and  therefore 
sometimes  cannot  be  reached  by  enemata.  In  many  cases  enemata 
of  salt-and-water  are  sufficient  to  produce  a  cure,  but  in  some  cases 
the  salt,  even  in  small  amount,  is  so  irritating  that  it  cannot  be  used. 
Infusions  of  quassia  may  also  be  employed  as  enemata.  One  of  the 
most  effective  methods  of  dislodging  the  parasite  is  to  give  every 
evening  at  bedtime  an  injection  of  60  c.c.  (2  ounces)  of  sweet  oil. 
This  is  allowed  to  remain  in  the  rectum  for  five  or  six  minutes,  and 
a  large  enema  of  water  is  then  used  to  wash  out  the  oil,  which  usually 
carries  with  it  the  parasites  from  the  lower  colon  and  the  rectum. 
Care  must  be  taken  in  regard  to  cleanhness,  so  as  to  prevent 
reinfection. 

When  this  treatment  is  not  sufficient,  lozenges  of  santonin,  1/6 
to  1/2  grain,  according  to  the  age,  may  be  given  two  or  three  times 
daily.  Every  two  or  three  days  a  cathartic,  such  as  castor  oil  or 
calomel,  should  be  given.  Care  must  be  used  in  giving  santonin 
not  to  produce  symptoms  of  poisoning,  such  as  gastro-enteric  irri- 
tation, dizziness,  and  yellow  vision.  The  occurrence,  however,  will 
not  be  common  if  in  each  case  the  effect  of  the  drug  on  the  child  is 


Intestinal  Worms 


507 


carefully  watched.     Serious  symptoms,  such  as  convulsions,  have  been 
caused  by  a  lack  of  care  in  using  this  drug  in  young  children. 

Under  this  treatment,  aided  by  high  rectal  injections,  the  worms 
can  in  most  cases  be  eradicated.  I  have,  however,  met  with  very 
intractable  cases  in  which  months  and  even  years  had  elapsed  before 
treatment  of  any  kind  was  successful.  In  such  cases  temporary 
relief  can  be  obtained  by  giving  the  child  each  night,  or  two  or  three 
times  a  week,  a  small  enema  of  oil. 


Fig.  107 


Oxyuris  vermicularis.     Ascaris  lumbricoides 

ASCARIS  LUMBRICOIDES 

The  ascaris  lumbricoides  is  a  long,  cylindrical,  yellowish- white  or 
reddish-yellow  worm,  pointed  at  both  extremities.  The  male  is 
distinguished  from  the  female  by  the  fact  that  it  is  smaller  and  is 
always  rolled  upon  itself,  while  the  female  is  straight.  The  length 
of  the  male  is  from  4  to  7  inches,  and  that  of  the  female  from  6  to 
II  inches.  The  eggs  of  this  worm  are  oval  in  shape,  0.075  mm. 
long  and  0.058  mm.  wide.     When  they  are  first  passed  they  are 


508  Diseases  of  the  Gastro-Enteric  Tract 

almost  transparent,  but  they  soon  become  yellowish  and  opaque. 
These  eggs  are  not  developed  within  the  intestine,  but  pass  out  with 
the  feces.  They  are  very  tenacious  of  life,  and  may  develop  under 
favorable  circumstances  after  many  years.  The  embryos  are  de- 
veloped outside  of  the  body,  and  reach  the  intestine  with  the  drink- 
ing water,  where  they  develop  into  the  mature  worm. 

The  habitat  of  the  worm  is  usually  in  the  small  intestine.  It 
may,  however,  pass  through  the  rectum  either  with  the  feces  or 
alone,  and  may  migrate  into  the  stomach,  esophagus,  or  nose. 
Sudden  death  has  resulted  from  the  entrance  of  these  worms  into 
the  air-passages.  They  may  also  at  times  enter  the  common  and 
cystic  bile-ducts,  and  they  have  even  penetrated  farther  and  caused 
abscess  of  the  Hver.  There  is  no  danger  of  their  perforating  a  normal 
intestine,  but  when  ulceration  has  been  present  perforation  has 
occurred. 

SYMPTOMS. — There  are  no  especial  symptoms  produced  by  this 
worm,  and  we  can  diagnosticate  its  presence  only  by  seeing  it  or  by 
finding  the  eggs  in  the  fecal  discharges.  The  worm  may  in  some 
instances  produce  a  feeUng  of  discomfort  or  even  colic  in  the  region 
of  the  umbiUcus.  Neither  of  these  symptoms,  however,  can  be 
depended  upon,  and  an  anthelmintic  is  required  to  determine  whether 
the  parasite  is  present.  In  certain  cases  convulsions  in  children  have 
been  followed  by  the  passage  of  a  lumbricoid  worm.  This,  however, 
cannot  be  accepted  as  conclusive  evidence  that  the  convulsion  was 
dependent  upon  the  worm. 

TREATMENT.— The  most  efficacious  treatment  of  this  form  of 
parasite  is  in  the  form  of  santonin,  which  should  be  given  in  the 
same  doses  and  with  the  same  caution  as  have  been  already  described 
in  speaking  of  the  treatment  of  the  oxyuris.  Instead  of  santonin, 
the  freshly  prepared  fluid  extract  of  spigeHa  and  senna  in  doses  of 
1/2  drachm  for  a  child  two  years  old,  and  i  drachm  for  older  chil- 
dren, can  be  given  two  or  three  times  a  day,  care  being  taken  not  to 
produce  too  much  irritation.  The  oil  of  chenopodium,  2  to  3  minims, 
on  sugar,  for  a  child  two  or  three  years  old,  and  8  or  10  minims  for 
older  children,  can  also  be  given.  A  cathartic  should  be  used  in 
connection  with  these  drugs,  as  well  as  with  santonin. 

TAENIAE— (TAPEWORMS) 

The  forms  of  taenia  which  most  frequently  occur  in  children  are 
the  taenia  solium  and  the  taenia  mediocanellata.  The  taenia  solium 
has  a  slight  projection  at  the  apex  of  its  head,  around  which  are  a 
series  of  hooks,  and  below  which  are  four  sucking-disks.  The  taenia, 
mediocanellata,  or  beef  tapeworm,  is  the  variety  which  occurs  most 
frequently  in  children.     It  has  a  blunter  head  than  the  taenia  solium, 


Intestinal  Worms 


509 


and  does  not  have  the  circle  of  hooks.  These  worms  vary  in  length 
from  20  to  50  feet.  There  is  nothing  especial  to  be  said  concerning 
these  worms,  and  we  refer  to  them  merely  because  at  times  they 
occur  in  early  life.  They  are  never  met  with  in  nursing  children 
when  breast  milk  forms  the  exclusive  diet.  There  is  reason  to  sup- 
pose that  raw  beef  juice  may  carry  the  eggs  of  the  taenia.  There 
are  no  especial  symptoms  produced  by  this  worm,  and  the  diagnosis 
is  made  entirely  hy  finding  the  segments  in  the  feces.  There  is  no 
especial  danger  from  the  presence  of  the  tapeworm. 

Fig.  108 


Taenia.     I,  without  head;  II,  with  head 


TREATMENT. — The  treatment  employed  in  expelling  this  worm 
is  the  same  in  children  as  in  adults,  but  we  should  be  very  careful 
not  to  irritate  too  much  the  sensitive  gastro-enteric  mucous  membrane 
of  the  young  child.  The  child  should  first  be  treated  with  laxatives, 
so  as  to  free  the  intestine.     Food  should  be  withheld  from  the  early 


510  Diseases  or  the  Gastro  Exteric-Tract 

evening  until  as  late  as  possible  the  next  day.  An  anthelmintic 
should  then  be  given,  followed  in  one  or  two  hours  by  a  cathartic. 
This  usually  results  in  the  expulsion  of  a  large  mass  of  segments. 
Great  care  should  be  taken  to  prevent  the  head  from  breaking  off 
before  it  is  expelled.  If  the  head  remains,  the  worm  grows  again 
and  the  treatment  has  been  useless.  The  anus  should  be  carefully 
dilated  during  the  expulsion  of  the  worm.  Sitting  on  a  vessel  of 
hot  water  seems  to  help  to  prevent  the  head  from  breaking  off. 

There  is  no  anthelmintic  which  I  have  found  pre-eminently  suc- 
cessful in  expelHng  the  taeniae.  One  of  the  most  harmless  is  the 
alkaloid  pelletierine  from  pomegranate.  The  tannate  of  the  pelle- 
tierine  can  be  given  to  a  child  from  three  to  five  years  old  in  the 
dose  of  from  i/6  to  1/2  grain.  As  dizziness  and  headache  are  some- 
times complained  of,  it  is  well  to  have  the  child  kept  in  bed  and 
lying  down  until  the  effect  of  the  anthelmintic  has  passed  off.  The 
oleoresin  of  male  fern  may  also  be  used.  The  dose  is  1/4  to  1/2 
drachm.  The  cathartic  which  is  most  useful  in  these  cases  is  Epsom 
salt,  2  to  4  drachms. 

It  is  hardly  worth  while  to  mention  the  other  numerous  anthel- 
mintics which  have  been  recommended,  as  they  are  usually  ineffi- 
cient. 

If  the  head  of  the  worm  is  not  obtained  and  if  a  considerable  por- 
tion of  the  segments  is  discharged  as  a  result  of  the  treatment,  it  is 
desirable  to  wait  a  few  months  before  making  a  second  attempt  to 
expel  the  parasite.  The  reappearance  of  segments  in  the  stools 
indicates  that  the  growth  of  the  worm  is  sufficient  to  justify  another 
attempt  to  dislodge  it. 

End  of  Volume  I 


i 

Date  Due 

' 

^ 

RJ45  D92 

1917 

Dunn  "^'l 

Pediatrics 


